Hi, everyone. We're going to get started. Thank you for joining us today. So I'm excited to be here with Dr. John Cianca and Dr. Atul Patel to ask the question, are you happy with your practice? We're going to talk about building a sustainable, fulfilling, and rewarding patient-focused practice. So I'm going to just talk a little bit with you about why this might be an important topic. So there's been studies looking at physician burnout. There was a big study in 2015 that showed that about 54% of physicians were burnt out. And this study was of particular note because in the study, physiatrists happened to be at the top of the list. So what they found was that 63% of physiatrists were actually burnt out. And what happens when someone has burnout? We know that there's increased rates of medical errors that's self-perceived by the providers. We know that there's a lower quality of patient care, lower quality of patient outcomes, and patient satisfaction scores start to decrease. There's also a decreasing work effort. And that leads to increases in physician turnover and can also contribute to things like alcohol and substance abuse, depression, suicide, and relationship issues. So there's been, since that study that I talked about, there's been some other studies that have looked at our specialty in particular. And so this particular study did show that there were, there was a pretty high number of burnout. And if you look over here, about 3% of physiatrists that answered these surveys said they were completely burnt out, 17% experienced constant burnout, and 31% experienced some burnout symptoms. But there was still this group over here, 38%, that felt like they were under stress. So the concern is, are these people going to move to here and here? And the answer is possibly yes. And what contributes to burnout? Well, increasing workload, increasing requirements. So all of these things that we have to fill out for insurance companies and all of these calls we have to make to get our patients the care that they need, all of that can contribute. But things within your practice can also contribute, increasing burden from your computer system or relationships with colleagues, patient load, those types of things. So what can we do to help with burnout? Create a positive work environment, reduce administrative burnout, or burden, sorry, create positive learning environments, enable technology solutions, and provide support to clinicians and learners. So sometimes this is possible, right? Sometimes you're in a practice where you might be able to actually make these changes that could help with burnout of yourself and your other colleagues, but sometimes it's not possible. So what happens then? Some people will decide to decrease their workload by working less, but others may decide to look into alternative careers. So there's lots of different careers. I mean, I always joke with people at work. What would I do if I didn't do this, right? But what some people do is they may go into industry or pharma, real estate, research, they may write books, something like that. But another option is to look for a different practice setting. So if you're in academic medicine, per se, we'll say maybe going to a private practice or solo practice is better for you. If you're in a private practice model and you decide that that's not exactly what you're looking for, then maybe making a change to another type of practice. So I'm going to have Dr. Sianka start, and I'm going to let him tell you guys a little bit about his practice. Thank you, Sarah. I'm John Sianka, and I'm going to move through this kind of quickly because I think more discussion would be better, but I did want to give you some background as why I think I'm not burnt out, frankly. So let me just go through a little bit. These are disclosures, if anyone cares. And these are my objectives. I want to give you a background as to why I became a physician and really the journey I took because I think that was everything. I mean, there was a point at which I had an idea, but it was the journey that's really made it more palpable, which is, I guess, an obvious thing to say, but it's important. And my practice is very strange to compare to others, but I think it fits for me. I don't know that I would have been burnt out if I did it differently. And then maybe I can give you some inspiration if you are struggling. And ultimately, I'm very happy and thankful that I've done it the way I did. This is my educational background. It's kind of traditional for the most part, although each of those steps took a lot to get in. I wasn't a real stellar candidate for any of these positions, but I got them. So I'm going to give you an overview first because it'll give you some way to consider what I'm about to say, I guess. I realize as I look back on my practice, I've been kind of building towards this all along. Even though I had an idea, I think it's really, as I mentioned earlier, the journey that was most important. I kept learning new skills. I kept pushing myself to do things that were somewhat novel. And they all eventually became what I do today. And I've said this many times to my learners over the years. Every time I went to take a step, there was nothing under my foot until it hit the ground. Though I consider myself fortunate that there was ground under me when I did land. And there was some frustrations early in my career, which again propelled me to make changes. So if you're burnt out, I would say that's probably a frustration. And I was probably heading that way. But I also never intended to do it that way to begin with. So it was more of a resistance that I would say I had from the beginning. And oddly enough, I'm now 30 years into things, and I feel like I'm just kind of getting it. About three years ago, I thought, well, maybe I'll retire, or maybe I'll find something to do. And then all of a sudden, everything clicked. So I'm grateful. I'm not going to spend a lot of time on this. This is just some of the quirky things about me. And I would say the one thing that stands out to me is that I'm kind of a control freak, and I didn't like people telling me what to do, especially if I didn't really respect where they were coming from. So let me just take you through some of my early... Can I ask a question? Yes, sir. Why did you say you didn't like mayonnaise? I've always hated mayonnaise, ever since I was a little kid. I think it's something about the texture, but yeah. I'll leave the room if there's mayonnaise in it. So I'm going to set this next few slides up in parallel. So my practice and my career, and those are obviously linked, but separate entities. And I had to nurture both. Can we do something about that light? I feel like I can't see anybody. Let me stand like this. Anyway, now I'm blinded. So I came to Houston thinking I'd be there for a year. And I did a fellowship. I was the first fellow at Baylor in musculoskeletal medicine. And that was very new at the time. Nobody really knew what that was going to be. And I was very fortunate that Dr. Marty Great Boys, who was the chairman for many years there, had enough courage and enough insight to try something different. So he hired me at a time when nobody knew how this was going to work. And so I started an outpatient practice, which meant no inpatient, just an outpatient following. And of course, there was none to begin with. So there was a lot of building that had to go in. We also partnered with a group that was independent physical therapists. We put together this place that we called the Human Performance Center. And it was collaborative. And it was sort of a thing to do then, was to have a multidisciplinary clinic. It's hard to make things meet and ends meet doing that sometimes. And that was one of the early struggles we came upon. It's like, well, this is a great idea, but it's not exactly flying financially. And so there were some struggles to get it going. It did work. But from my end, I was trained, my mentor was very big into spending a lot of time with people. And so that's what I was trying to do. But of course, systemic medicine likes volume and likes reimbursement. And I didn't. I mean, not that I didn't like making money, but I was a physician first. And I took that to heart. And I wanted to spend the time I needed to take care of people. And I'm not a fast thinker. I'm kind of deliberate. And so that was a struggle for me. And it went on for most of the early years of my practice. In my career, I was getting off to a pretty good start. I started to make a little bit of a name for myself. I got asked to be the medical director for the Houston Marathon, which was a little daunting, frankly. But I took it because I felt like it was something I shouldn't and really couldn't say no to as far as my career was concerned. And I collaborated with some colleagues, and we did some things. So that's what you see there on the right. So as we move into sort of the second part of my practice, I realized at the very last year of my practice, and ironically, the leadership, not the chairman, but the administrative workers at the department, suggested that I go to a cash-based practice. And I wasn't so sure about that. It was kind of frightening. I kind of got comfortable with it finally after thinking, well, if I lose half of my patients, I'm still going to make the same money. So I thought, well, that may not happen, so I'm going to try it. And it was successful right from the beginning in terms of the finances of it. Interestingly enough, at the end of the year, the same administrator who suggested it to me said, eh, we can't really do this. It's not really the way Baylor does things. So writing was on the wall. Either I go back to the way it was doing or leave. And again, Marty, to his credit, Dr. Gray Boys, allowed me to leave, stay where I was, and continue to have an affiliation with the department, which I still have to this day. So I started out on my own, but still had the same infrastructure around me. So it allowed me to really keep going with what I had already started to do. Very fortunate. I really could never thank Dr. Gray Boys enough. And I started to do some things, add-ons, that were different. I got into ultrasound. I got into regenerative techniques. I had already learned acupuncture at that point. I did that early. So my practice was becoming more dynamic. And of course, I was still with the Houston Marathon, which was helping, not financially, but from a reputation. My career was going along OK. I got involved with the academy, did some work with them, first in ultrasound, and then towards the end of that phase in the medical education committee. I published a book in ultrasound, which was a daunting but very satisfying task. And then I started getting paid by the Houston Marathon to be medical director, largely because it was taking up a huge amount of my time. And I said, look, I've done this 17 years as a volunteer. I can't keep doing it this way and stay sane and or solvent. So they started paying me, which was helpful, too. At the same time, I dropped Medicare, which was a big hit to my practice, because it had So now I was completely cash, no private insurance, no Medicare. So having the Marathon as a backup, and then this other company that I started working with, Second MD, was really helpful, because that buffered the lack of volume in my clinic. So I could still keep practicing the way that I wanted to without the pressure of volume and having some financial backup. Now keep in mind, I wasn't getting rich. My salary is probably less, way less than the median salary for a physiatrist. So I got a unique personal situation, too, so I don't have a lot of overhead. And that allowed me to basically keep food on the table without making a lot of money. So along the way now in this last phase, which I really feel like I'm just starting to do things the way I always intended to do them, I started doing some additional work, some little bit of medical legal. So now I'm doing Second MD, which is an across-the-nation second opinion service through this company, Second MD, which started in Houston. And fortunately, again, one of my residents was the CMO for the group, so she asked me to participate. I don't know what would have happened if she wasn't there, but it came to me, so I feel grateful. And, again, I started to continue to add things to my practice, most recently shockwave therapy. I resigned from the Houston Marathon a few years ago because we had sort of an ethical disagreement about holding a marathon in the middle of a pandemic. I didn't think it was a good idea, so I thought, I got to move on. And then I've moved up in the academy as well. So that's encapsulating my career thus far. I do a lot of different things in my practice, so I'll just highlight these real quickly and let Dr. Patel talk. So I've always wanted to work in sports. That was something I decided before I even went to med school. I was a bit of an athlete, but mostly I was really intrigued by the combination of biology and movement and sports. So that was the direction I wanted to go, but I didn't know how to get there, as I said earlier. So I took a lot of steps with not a lot of certainty underneath. And I was fortunate that I came in on the ground floor. As a physiatrist, there was nothing really before me, not in any sort of structured way. There was only two fellowships in musculoskeletal medicine and physiatry. There was a fair amount in primary care and orthopedics, but that I learned very quickly that wasn't going to work for me when I went on the interview trail. So I had limited options, and I stumbled upon the fellowship at Baylor just because I happened to talk to a colleague who knew that that was going to happen. It wasn't announced. I talked to him. He mentioned my name. I'm the only person they interviewed. So what happens if I don't talk to this random person at an interview that I knew I wasn't going to follow through on? So again, very fortunate for me. And along the way, even though I was doing what I wanted, my notion of sports medicine changed. It really was not about the patient population, but about the style of medicine I was practicing. And I like to think I'm a sports medicine practitioner, but I apply it to everyone, not just athletes. Acupuncture, I started early on in my career. In the early 2000s, again, on the front end of that, I was deemed an expert way before I was an expert, and that was a little uncomfortable, but it'll push me. Orthobiologics not so much on the front end but early. And I've been doing those a while. And then most recently as I said with a shockwave. So I've got a whole list of things I do. It makes my practice pretty diverse day to day. I'm doing one thing or another but rarely the same thing. So it's satisfying. The second M.D. part I mentioned and I'm doing a bit of work in medical legal. But frankly that makes me a little uncomfortable being in front of lawyers. So I do some of that. And then I may get into lifestyle medicine. That may be the next thing I do even though philosophically I'm probably already doing it to some extent. But I'm not trained. So I'll give you some final thoughts. I'm going to let Dr. Patel come up. I think it's important to know from the beginning what your goals are and to keep them in mind always realizing that how you get to those goals may change over time. And it certainly did for me. But ultimately I got to where I wanted to be. So you've got to have a vision. Priorities are important but you have to be flexible and patient and ultimately trust what you believe you want to do. Because if you're not doing what you want to do you're not going to be happy. I don't care what the environment is. Again I'd say I'm grateful that I was had enough insight to know that along. Even though I didn't know that I knew that in my soul I think I did. And I kept directing myself that way. And you know despite having to make some decisions that I thought I'm not sure this is going to work and they have. And I don't know if that's just good luck or if it's what we all need to do. And you know again believe in that vision. So that's how I got started. That's what I do. Dr. Patel please come up and give us your format. Thank you. And again good afternoon everyone. Oh yeah that light is bright. But I guess we're being recorded. OK so fine. I'll put up with the light. You know I wanted to just make a couple of comments based on just from listening to your presentation John. And I think you guys are looking for ways I'm assuming to learn from some a couple of people who've done it in different ways and learn from our experience. But a thought that came to my mind number one with your Sarah what you mentioned about burnout and all that. And there's so many different factors where people get burned out. Right. But one of them might be the lack of control. You've gone through all this trouble and then you don't have control. So let's keep that in mind. And then the other thing was just listening to your career and I've known you for a while. I'm just listening again right now. I think two three things came up to come to mind right away. And one is really know what you want to do because if you know what you want to do you'll get there somehow. Number two be prepared to make bold moves. Change. Because things happen and you need to make scary changes. But you need to do that. And then the third thing was opportunities there. Right. You're saying it was luck or what. But people somebody said hey you want to do this. And he said yeah. And you thought they just came along. But there's opportunity all the time. So keep that in mind. And I think that's how my career has been is it's like it's all luck but it's maybe not all luck. OK. So I guess I'm going to look at this. Yeah. All right. So just a little background on myself. My first job after residency was in KU at KU Medical Center. I went to medical school at Baylor and I actually had a connection with Dr. Marty Grayboy. That's another interesting thing. I was a third year medical student. I wrote a letter to him. I said I don't know if I want to go into this field but if I do go into this field wouldn't it be nice for me as a medical student to know about the field and then become a future leader. I don't know why I wrote that to him. And he paid for my way to go to the American Academy meeting. That was great. So again sometimes you have to speak up and ask and you never know you're doing it. And it is what you end up doing some somehow. So I became an assistant professor then became an associate professor and then went to. While I was doing that I was also a medical director of an inpatient rehab unit. I was also a residency program director. I also was doing research and guard grants and just I'm giving you all this background so you know where I'm coming from. Right. So I mean in academics I've done all this other stuff. I became tenured and then the year I became tenured I quit and that was one bold move. Right. I'll tell you about that in a minute. My second job Kansas City Born and Joined I joined an orthopedic group. I wasn't going to do that. I was going to leave town and my wife did not want to leave Kansas City. And I said OK. And at the same time the orthopedic group independently asked me to join them and I said do what. And they said do whatever you want. I said really. This will last for one year. It lasted. It's been 23 years. I just had a 23 year anniversary at Kansas City Born and Joined. I'm the vice president of the group. But what I did was and what makes me different or unique and all of us are unique in different ways. Right. But I have been able to do academic medicine or what you would consider like an academic academician in a private practice. So I've done about 20 plus years of research now. I do research. I write articles and publishing. What does what else do people in academics do. They do administrative work and belong to organizations and give back to nationally. Right. I'm on national organizations. I'm on the American PM&R board. I'm the treasurer. I've been doing things like that. What else do the people in academics do. Educate. I enjoy teaching. So I've been teaching at national meetings locally nationally internationally and I give lectures all over the place. I've kind of fulfilled all those goals and it didn't happen overnight and it wasn't done with intention all the time. I've got to get this. I got to get this. It just just let it happen. And one of the presentations I had during this week I think I should have put that slide in here. And that was my life experience. Sometimes you keep looking for a path but just take the path that's in front of you. Just go and take that first step and then keep looking for things while you're doing that. And that's one way I think you can stay happy and have a good career. What happened. OK. So some key factors right. How do you. What did I do and what have I learned. I think you really need to know yourself. You need to know what you want. And that's a really hard thing to figure out. Right. Because all this time you've gone through college med school residency. It's always been what do I need to do to get the next step. You don't even have time to sit down and think what does whatever your name is for me. What does a tool really want in life. It's a hard question to answer. But these need to start asking that question again and again and realize what you really want. Number one. Number two what drives you. Because if you are in a situation where you don't like it you will never have fun. And then the flip side of this is whenever you're doing something overall are you having fun. Ask yourself that every day. If you're not having fun you need to fix the problem or get out. Right. And I'm going to come to that. You don't want to just keep jumping all the time because that doesn't make sense either. Do you need intellectual satisfaction. So for me I do. I really could not do the same thing again and again. The way I grew up and everything I always have to do something different. Sounds like you're doing different things all the time too. And I think all of us were highly educated and we want to do different things. We don't want to be bored. We want to be intellectually satisfied. So look for things that will make you satisfied in the existing job. Are you growing. Because I heard from a psychologist the moment you stop growing you start dying. Right. You've got to keep growing. You've got to be growing intellectually. In other ways your practice is improving you're enjoying life and the things like that. If those are things that are not happening you need to put energy into those things and try and make those things better. What do you want your professional career or life to be. This is a sound like a real simple question. It's a hard question because when you first come out and I don't know if any young people in residency or something like that the lights so bright and I can't see anybody. But I would really ask the question now is like really do you want to make more money or do you want to make. What do you want to do. And are you doing things because other people are saying that you should do that. And so you could say if everybody's saying going to brain injury are you going to go into brain injury because that's the thing to do. And I'm using that as a weird example because most of the times I know what people are hearing right now. Right. 80 to 90 percent of our residents in the past at least in the recent past have all gone into musculoskeletal pain management spine procedures. Right. But if that's all you're hearing don't be don't let that drown out who you are or what you want to do. And do you want a job or do you want a career. You got to ask that. And you have to look at the long term outcome. What do you want to be able to say after 30 years of working. What is it. What do you want. So that's again going back to what drives you. Who are you. And what do you want. And keep those things as a baseline. Maybe once a year look at that. And that might even change over time. Are you comfortable with your situation. So wherever you are you have to make sure that you're enjoying this potential for growth or something like that. So go back to my situation. Right. I wanted to be in academics. My as soon as I decided to come out of residency I did get an academic job and I said OK no matter what I'm going to give it my all. I worked super hard. I got tenured. The year I got tenured I asked for a sabbatical. They said no. I asked other people to write papers with me. They said no. And I said to myself what the hell am I doing in academics if these guys don't want to be academic. So I say half jokingly and very seriously I left academics to be more academic because all the things I wanted I have now slowly made for myself. But if it didn't work I would have tried something else to figure it out. Right. The other underlying principles I want to highlight is do not cut corners. And I'll come back to that a little bit. Don't compromise your values ever. Just don't do that. Even if somebody asks you to do something you think it doesn't feel right. Listen to your gut. Don't do it. And don't be afraid to make bold changes. That was the one thing. You've got to make it. So I mean I come home one day and tell my wife. Guess what. I was also doing a master's in health administration degree at that time and we did this exercise and that just proved it to me. I was in the wrong place in one of the questions. Are you surrounded by people who want to work with you. No. Are you surrounded by people who want to who who motivate you. No. I said I'm in the wrong place. I came home and I told my wife in order. Number one I'm quitting. Number two I have to find another job. She said what. I said yeah I'm quitting and then I'm going to find a job. So I turned in my resignation the next day. Right. So you've got to be prepared to do that. But you need to know yourself. You need to be confident but not overconfident. So that's what I did. So I made this up. This is not a thing I've used before but I thought hey Patel peas. Hey I started with patients pragmatic. So let me talk a little bit about this. You've got to be patient. You cannot make a bold movement just as the moment something doesn't work. You've got to be patient. I remember when I got to that program the residency program was falling apart. It was not even accredited and they lost their accreditation and there was nobody there to run the program. I said OK you know what. Roll up my sleeves. I'm right out of residency. I'll become the program director. Then the ACG I mean the RRC committee came to review us and they said wait a minute. There is a rule that you have to be out several years before you can be a program director. They looked around the rest of the department. They said you know what. We'll make an exception. Right. I got the program fully accredited in that two year period time. I was a program director for four years. But again whatever you do don't cut corners and make it the best you can. So that's what I did. That was my plan. I just work and be patient and see if I can make the place better. So don't have to necessarily just jump right away. You've got to be pragmatic and think ahead and plan things out and see where things will land and be both optimistic but also very realistic as to what's going to happen and make sure it makes sense and plan things out and see if you can get there because that's the only way you know we're going to go. You don't want to just work hard and not know where you're going to end up. You have to have an idea where you're going and what you want to end up. And that answer comes from earlier knowing who you are and where do you want to be. Right. Whatever you do be passionate or just don't do it. When I hire now I'm in private practice I hire staff. I don't look. I'll give you a simple example. If I ask for a glass of water can you do that for me. Yes. Can you do a really really good job at it. They say yeah. I said what if I'm not watching and the glass has a little piece of something stuck on it. We're just going to flick it up and still give me the glass. If you get that kind of person I don't you don't you don't care. I'd rather you tell me I cannot do it. I'll get your glass maybe dirty water but just tell me that I'll get my own water. You don't need to. But do not compromise. Just tell me exactly what you're going to do for me and I'll know how to work with you. And that's the same thing you should do when no one is watching do the right thing and be really really passionate about whatever you're going to do. So if you feel like you're not going to be that passionate about something don't do it because it I think affects your insight and if you're doing something with your full energy and enjoying it you will have a good time. You'll sleep better and nobody will ever question whether you put in everything or not process more than just the thing that now you're going to go about it. But the process is you've got to make everything efficient because why are we getting burnt out. We don't have control. The fluff the fluff in medicine and the money is going away. It's becoming super hard in my situation in private practice to operate. But I'm sure that's happening in academic institutions everything. The fluff is gone. It's not that much fluff right. And so you have to be very efficient. So if you're in an academic center if you're working with residents if you have your own clinic or whatever you want to run that super smoothly right. And you want to have fun. At the end of the day you must get out of the day and say I'm overall I'm having fun. Not every day is going to be a great day but overall it should be a fun experience. And the best way to do that is find all the things that you can change and make them better. I can't change the address of the building. The location is location allows the location. So don't spend time griping about. Oh gosh we're stuck on the bad part of town. If you're working for somebody else that's it. You're there. You can't change it. Don't waste a single moment of energy on that. Spend your time on figuring how you're going to make the place safe for example. How are you going to do things around and all that. And the people you're working with make them happy and empower them so that they can also be very helpful in making your practice successful and progress. Make sure you're making progress. The moment you're not growing the moment you're not making progress you're becoming complacent. You're becoming stagnant and you're going to be out of date. And then before you know it you're going to say gosh what happened. Everyone else is using AI and I'm not. You're going to be you're going to be left behind. So don't do that. Always keep progressing happiness. I think people have talked about happiness in philosophically and everything. But really it has to do with certain things. If your expectations are not met you're going to not be happy. So you have to have expectations. But are they realistic and maybe a little bit lower than what you think. And if you can do that then I think you're going to be better off when things work out and you're going to meet your expectations. But you have to have realistic expectations and you need to be willing to change them if things are not working out because medicine is everything is a moving part. Right. So medicine is changing what physicians made before or how he was the first person to show up at a residence fellowship program and got in. You may not get in. It's much more competitive. Everybody wants to do it or something like that. So you can say you know what didn't work. Knock on the door again. It didn't work. OK. I've got to start looking for something else. But have that attitude that doesn't matter. Whatever you're doing you're helping patients you're helping yourself. You're going to keep moving and pivot reality and perceptions. You need to have a really good idea of what's going on and perceptions. You have to have a really good perception of what's happening around you. Don't be fooled by things that really look shiny and great, or the grass is greener on the other side. If you're wherever you are, try and make that place better before you jump. Gratitude. I mean, just put yourself in a situation. Most of the time, you're going to be better off than every patient you see. And spend time with your patient, and enjoy that interaction with that patient. See how you can truly, as one human, help another human. I got a lot of joy out of that. And that's what keeps me going. It keeps me from getting burnt out. Gratitude of my staff, gratitude with my patients, everything, and just helping them, and overall attitude. And then, virtue. What is virtue? Virtue is, you know, the practical wisdom. That's how Pluto defined it, right? Plato, sorry, not Pluto. Plato. Pluto probably had some philosophical things to say, too. Plato said that virtue is practical wisdom. And that's your collective experience. Learn from your own self, and stay virtuous to yourself. I mean, make sure you're doing the right thing. And let me give you some example of what's happening, and the way I see the world, right? I think a lot of people right now are not getting the full spectrum of what PM&R is. Or you may feel like, oh, gosh, everybody says, better not do that. Doesn't really pay. You better want to do this, otherwise you won't make enough money. Listen to all that, but think about it. And then see if you really like, say, for example, I do a lot of spasticity. But spasticity doesn't pay as well as some of the other procedures, right? But you could still say, I'll take care of patients with neuro-rehab. Maybe I'll do just a small portion of it, and then go from there. Also, deal with whatever you have. Am I doing OK for time? Please keep me in check. I can keep talking forever. Keep checking and seeing how things are going, and if you're making money, and what you enjoy. Because you can keep slowly incorporating things into your practice. So now I'm going to switch gears real quick. Building a practice. Because I think one of the ways to be successful as a practice and in your career, and when you have that success, it will also make you happy, right? But if you're also focused on making your practice better and all that kind of stuff, and you have control, even if you're not making much money, you're going to feel good, right? And you don't have to make money from day one. Really, I think somebody else had presented this in another presentation. I don't know if you guys were in there. But don't make money your number one goal. If you do, that's fine. If you really do want to do that, most likely you're in the wrong place. I'm telling you. You can make much more money doing other things than doing medicine right now. And in fact, that reminds me of a story. When I was, this is a long time ago, and when I was applying to medical school, one of the interviewers asked me, how do I know you don't want to go into medicine to make money? And I was just finishing up my chemical engineering degree. And I said, you know what? If I stayed at home for four years and worked at the lowest salary a chemical engineer makes, then for another four years, I will not work for minimum wage. I'll still stay at home. And that's eight years, and I'll not have any loans and all that money. And then I just take that money and put it away and go to the doctor. And all that money. And then I just take that money and put it away. He says, stop, stop, stop. Okay, you're right. You're gonna make way more money. You're not in it for the money, because there's a lot more ways to make money than medicine. Building a practice. Get to know your current situation. You really need to know who the players are today. And when I say, if you're coming into an academic century, you're coming into a new job, or wherever you are right now, don't have to change anything. Just learn the lay of the land. Look at everything, observe everything, and then start making little changes. What can you change and make it better for yourself? If you don't have control over something, see if you can get control over it. Like scheduling patients. Educate the right people to help you with those kind of things. Because at the end of the day, you don't want to be ticked off and they're putting a brand new spinal cord quadriplegic patient at the end of your day, or something like that. Or the first patient of the day, and then you can't, you're already behind. You can educate people and take control of those things. Just complaining, make things better for yourself. Try and figure out what you like. So slowly over time, just take what you want. When I came out of residency, I thought I was gonna do electro-diagnostic medicine, and then I was put in an inpatient unit. I said, I could do that on the side, and the next thing I know, that's all I was doing. I wasn't getting time to do anything else. And I had to slowly figure things out, but then I also started liking stroke. So there might be something you didn't even know you liked, and then all of a sudden you like it, because that's the patient population you have. So work with what you have. What does the community need? So I've always asked that. What does the community need? What does my patient need? What does my community need? And that has defined my practice and how I've grown. And I'll talk more about that during Q&A if we need to. I don't want to spend too much time. I started out very broad, and as you get busier and busier, then you can pick and choose what you like, and start focusing. So you can just say yes to everything in the beginning, and then slowly start saying no to things, and narrow your focus, and do the things that you like the most. You guys have heard about the A's in medicine, right? Being available, that's very, very important. You can't say, well, you know, Friday you want to see a new patient? Oh, no, I'm not available Friday, I leave early. You do those kind of things, your practice is not going to grow. So when you're first building up a practice, you need to be available, number one. You need to be affable, and able, and affordable, but accountable as well. So you need to provide really good care, and if something goes wrong, you need to be accountable for that. So just do it right, do it well, and be available in the beginning, and just take everything. Even if, for example, I'll just make up an example. Even if you don't like somebody with stroke, you don't want to do a stroke, and you want to do musculoskeletal, for example, take really good care of that patient. That patient probably has a family member who has back pain, who has shoulder pain, who has knee pain, something like that. And next thing you know, they'll be all coming to you, and that's how I build up my practice. I just take care of whoever, and the next thing, the family says, oh, you know, my daughter just had a problem while playing volleyball. Do you do that? Yeah, I do that. Yeah, I'll do everything. And you build it up, and then get them to the right people. So that's how you build up your practice. Don't worry too much about pay and revenue. At least that has been the case for me. I don't know how the world is right now, but I did not worry about money at all. I just took care of the patients, and it built it up, and I've done well, I think reasonably well financially. So I think it all works out. Let your work speak for itself, really important. Do not cut corners. Every single time you do something, and other people don't know us, so we're all ambassadors for our own field. There's so few PM and R. One of the most common things we hear is that nobody knows what a PM and R doctor is. Well, be the agent of change. Every single time somebody says something, don't tell them you're a pain doctor. Tell them I'm a physiatrist or a PM and R doctor, but I also practice pain management. I'm not a sports medicine doctor. I am a physiatrist, a PM and R doctor, and I also do sports medicine. Always tell them that, and then if we all did that, it would make a big difference. I have patients who come from another PM and R physician, and I say, who did you see? I saw a pain specialist. I say, was he an anesthesiologist or a physiatrist or a, they have no clue. They just say he's a pain management. So our own people are not using the term, and if we all used it, that would help. I think I can, I'm gonna skip some of these. I wanna really open this up to Q and A. Okay, so visit referral sources. Give talks to appropriate groups. That's how to, efficiency. Yeah, start out slow. Whatever you do, whatever you wanna do. So I'll give you examples, and you guys can ask me in the Q and A how I've started doing different things. Some of this is repetition, so I'm gonna skip that. Other factors. I'm in an orthopedic group. You have to earn respect. From day one, I told them, you're gonna treat me equally, and that would have been a bold move. If they didn't make me a partner, I'm ready to quit. Here's my resignation letter right there. So you have to, you wanna do that. I wanted to be treated equally, not as a PM and R doctor. And this was a little while back, but I haven't heard that ortho groups can do that, because I say, if you ask me to join you, yeah, you're gonna make me a partner, right? Within a year, you already know me, and you're gonna treat me equally. Earn your keep. What do I mean by that? When they have a 6.30 meeting, board meeting, I'm there. When they're talking about which joint they're gonna use, which three joints they're gonna use, I'm there. When they're talking about where they're gonna take call, am I taking ortho call? No, I'm there. I never give them a reason to say, this guy's not part of our group, right? I'm the vice president now. Pick and choose your fights, yeah. You may wanna get a new piece of ultrasound, a new equipment, like an ultrasound. Figure out how you can do it. Show them how you're gonna help them. So you gotta learn that, and you gotta get better and better at negotiating with the people, but you gotta pick and choose your fights, and do not compromise your values. So if they say something, and you really know you need to do it, I remember when I first joined the group, they were so nervous. So you want us to buy an EMG machine, and then what if you leave after a year? And I just told the guy, you know what, I'll buy it. He said, okay, fine, we'll buy it. Right, I just told him to his face. If you're that worried as a group that you're gonna buy an EMG machine, I'm gonna use it, I'm gonna help your patients, and you're worried, and I'm gonna leave in one year, who's gonna take that machine, and are you gonna be stuck with those $20,000, $30,000? I said, I'll buy it. And they said, okay, you make a lot of sense. Forget it, we'll buy it. So you gotta know how to fight with your faith. I'm gonna stop right there. Thank you. I don't know how much time we have. Go ahead, Mark. Good. Do you wanna come sit here? Yeah, hop on. So we're gonna do questions. I'll start us off, but is the mic in the middle working? If people wanna, okay, perfect. So one thing that I noticed, Dr. Sienka, about what your career has looked like is you've pivoted a lot. You've added things to your practice, kind of always kind of that cutting-edge time when they're just starting to become, you know, ultrasound and then shockwave therapy. How have you decided when it was time to pivot or to add these new skills to what you're doing? Okay, good question. I actually, I'm pretty deliberate in the sense that I don't, I kind of wait for things to show what they're worth. Like, let's take shockwave, for instance. That's a relatively new addition. Some of you may know what it is, some not. I was in San Antonio in 2019. I'd been hearing about it a little bit. I heard a couple colleagues speak about it. I thought, hmm, okay, let's think about it. And I gave it a couple years. And, you know, the more I considered it, the more it seemed like a worthwhile move. You know, it wasn't entirely bold, but I did it at a time when it was still relatively new. But I'd done some due diligence on, is it working, is it something that's viable? I also had to make the decision about, can I afford it? You know, I'm it, I'm my boss, but I have to front the money, too. So, you know, it's some of that. You know, consideration for, will this work for me? Will I get what I need back from it? And is it gonna be helpful? You know, so I was at a recent meeting and there was some vendor that was trying to sell me on laser. It looked like it was a good idea, but I don't need to spend $70,000 on it when I'm already using something that kind of does the same thing. So, you know, there's a little bit of thought that goes into what you implement. Are you, one, do you think it's gonna work and is it financially viable or potentially so? Don't get, you know, don't just grab everything just because it's out there. Think about how you're gonna use it and, you know, what it will do for you in both your practice as well as your business. Anyone else have questions? I have another question. Can you guys share a little bit about what a typical day looks like for you? Are you seeing patients five days a week? What is your schedule like? Yeah, actually, that's a great question. Every year, my practice looks different. Every day is different. But during that one period of time, my days look fine. So right now, this currently, I don't know, Mondays and Fridays are completely nothing, but EMTs smattered with other procedures on the side like a botulinum toxin injection for hyperhidrosis or cervical dystonia. No, no, cervical dystonia. Wednesdays, all day Wednesdays, cervical dystonia. But it could be migraine, could be hyperhidrosis, could be spasticity. Tuesday afternoon is all simple injections. Anybody who's straightforward, I know they're not gonna ask too many questions. They even have to raise, can I ask a question because they're that well-trained? Okay, if my patient is late, if my patient is late, they know they're gonna wait till the end or come back another day. That's how efficiently I run. So if they show up early, they say, wow, I am out before my appointment time. I say, yeah, perfect, thank you for showing up early. If you're late, I'm not gonna make anybody else late. You're waiting or come back on a different day. If it's an emergency, I'll drop everything and take care of you. So that's, so Tuesday afternoon, Tuesday morning, I go to Children's Mercy. Tuesday afternoon is all the simple injections. So I pack them in. Wednesday is all the cervical dystonia. Thursday is everything complicated. So that's the day I know I'm gonna stay late, I'm gonna work hard, doesn't matter. Whatever questions you have, just that's the day that a patient goes in. Friday, I wanna go home happy and not too tired. So I just, whatever's left over, it's called a fly-in Friday because now I've got so many patients that fly in from out of town to see me. So that's fly-in Friday and EMGs. So I didn't mention this, but it's kind of important to know. I am a solo practitioner. And when I say that, I mean, I do everything. I answer the phone. I check people in. I see them. I check them out. I schedule them. That wasn't always the way it was. I did have an assistant, an administrative assistant, not a clinical assistant. For a long time, she left. Fortunately, I got a new person who I like quite a lot, was good. She was probably overqualified, to be honest with you. She was a physician who never went on to internship and residency because she started a fellow or started a family, and she was self-serendipity, but she wanted to kind of get back into medicine. So anyway, she left in January of 2020. We all know what happened, what next? I'm not hiring anybody in the middle of a pandemic. And then, so in the time that we were operational, but not at full capacity, I kind of felt like, oh, I can do this. So I'm still doing it that way. And it saves me about 30 or $40,000. So my day is busy from the time I get there to the time I go. I come in in the morning. I'm usually getting everything up and running. I might answer emails that come in overnight, phone calls I usually try to get done by the end of the day. There might still be an overnight call. Then I start, either I do a consult with second MD, or I start with a patient. It could be a new patient, could be a follow-up, might be a procedure. In that sense, it's pretty free-flowing. Whatever I schedule, it's scheduled. I might, when I do get a medical legal case, I usually kind of put that by itself because I never know how long it's gonna take. So it's pretty variable, but I'm always busy because if I'm not seeing a patient, I'm trying to do something else. I can return an email, fax this, do that. It gets a little tricky when something disrupts my day, like a scheduling software going down, which is a real catastrophe. And that happened not too long ago. So those kinds of things are stressful. And you do have to kind of anticipate that that might happen. So as much as I can, I try to create some spaces so if something happens, I can deal with it. I don't want the situation where one patient leaves and the next person's waiting to come in because I know between patients, I gotta check that person out, I gotta, you know, I don't really have to bill, but I have to put things where they belong in terms of my bookkeeping. So I need a little space in between. And so if something else happens, it can be a little disrupting. So that's kind of my day. Friday, I try to end early. So I see patients in the morning live and then I do a couple consults in the afternoon, but I still don't go home until five o'clock because I'm getting ready for the next week. So it's busy without it being clinically busy all the time. Thank you. We have a question from, were you gonna say something? Go ahead. I was gonna add one more thing. And again, getting help is not, yeah, and getting help from other people, so either hiring another physician or something. In my situation, I have. We have a question from the online participants. Dr. Patel, how have you been able to balance your academic activities while in a private practice setting? I'm sorry, go ahead and ask the question again. That's OK. How have you been able to balance your academic activities while in a private practice setting, both in terms of time and compensation? Oh, very good question, yes. So again, whenever you're investing in yourself and doing something new, be prepared to take a little bit of a loss, right? And then if that's something you really enjoy and you get better at it, then you start making, you get financial rewards from it. So with research, I just enjoy doing it and everything. I started doing it not with the intent of making money. And then over time, I have been able to turn that around. And clinical trials actually make good money. But I'm, again, always careful about, am I doing something to chase the dollar? Or am I doing something because I enjoy it? Or am I doing it because I'm helping the patient and the community? If it doesn't fit some of those criteria, if it's only because of money, then I back off. And I've done that with many. And I can give examples later, if we have time, how I've done that. And how do I balance? That's a tough question. Naturally, sometimes things slow down in one area. And I can pick it up and do it in the other. But I do a lot of work after work. So I do do all my writing and stuff like that at the end of the day or in the evenings and on the weekends. So research and all. And I got used to that while I was in academics. Because even though, quote, unquote, I had protected time, I never did. So I was really used to just doing my research at the end of the day and non-clinical times. Yeah, go ahead. You can yell it out. And I'll repeat it so that the audience can hear it. Or you can walk up here. It's up to you. OK. So doctors, thank you for sharing your experience. It's varied and inspirational. The question I have for the panel is this. You guys have done a lot of stuff. Have you ever thought about circling back and doing some of the stuff that you put down in the past and then picking it back up? Yes, sometimes it happens organically. Early in my career, I was doing like a third of my time I was doing acupuncture, running a couple of rooms at the same time. You can do that reasonably well with acupuncture. You know, once you put needles in somebody, you're gonna leave them alone anyway, so I can start with somebody else. And then as I got into ultrasound, that kind of waned a little bit and I really got heavy into using ultrasound and teaching ultrasound. But more recently, I've had patients requesting acupuncture again. So you do have to stay current. So that's an issue when you put something to the side. So I'm a little bit more careful about deciding when to do ultrasound or do acupuncture now, just because I haven't done it nearly as much as I did years ago. But I try not to lose anything, meaning stop doing it entirely. I might just reorganize what I use and how often I use it. Any bits of advice as to how to keep current on things that you might do a little bit less of later on? That's been a struggle with me for acupuncture, right? I went early in my career, I took most of the stuff that was available. And then it becomes, you know, ideally I'd say if you were gonna learn acupuncture, have a real mentor, because it's a very acquired talent. I mean, you can learn the basics of it, and then there's only so much available that way. And you really have to have a good mentor. I didn't have a mentor, I guess. So that probably is a limitation in my skillset. But yeah, there are some things that, you know, you may run out of resources. I can add to that real quick. So there are other ways to also do it, right? So let's just take an example. Let's say you were doing electrodiagnostic medicine early in your career, then you stopped doing it. Now you're super rusty, right? So pick it up again. You gotta figure out what's going on. Maybe go to a course again. Even places like AAPM and I, we had a reboot or a bootcamp for starting to do EDX again. So something like that, go to that. And then you can start doing something simple. But I will say this, don't do things just for the money, right? Let's say all of a sudden, something started paying more and you're gonna do it. Ask yourself, are you doing it for the money or for the patient? And then I always ask the other questions. I take it to the patient. If I were the patient, would I go see me for this? Who only does EMGs once a week and only knows how to diagnose carpal tunnel? No. So then don't do that to your patient either, right? That's the way to do it. So get your proficiency up because then nobody can argue with you and also you'll feel so much better that you did the right thing for your patient. You don't need to know everything, but you need to be able to recognize that it's more than carpal tunnel. I need to send you somewhere else. Thank you, guys. Thank you. My name is Ishan Ahmad. I wanted to say that I really enjoyed the discussion or your presentation because it was full of how and what you experienced during your 20 plus years of practice. In reality, as I'm listening to your lectures, I'm also thinking that it is very different for a person who's graduating from medical school or from residency. They're young. They probably found a girl or a boy. They have a kid and they want to settle down. Those decisions which some of you took during this time frame might not work in a person who really wants to settle down in a place. And when you look at jobs, there's a hospital job, there's a private job, there's a locum job. You keep traveling everywhere. I just found out how locum job works yesterday. There was somebody who was marketing locum jobs. So for a person who is really married, have kids, the kids are going to one place, he can't actually do locum jobs. But then as new residents, they don't have a choice to select something really according to all those wishes that you are saying. And I personally feel that I have changed two jobs and because the first job that I joined, I was so excited. But then I realized the hospital politics or how they work, I was really trying to find time to really rest in that practice, became overworked. The only thing I wanted at that time was some time to go and rest. You know, that was not a choice that I could have made myself. Any comments there? Yeah, perfect question. I'll give you my real example. I have a wife, I do have kids. I did not want to live in Kansas City. I've been there all my career, okay? That's number one. Number two, bold move, I quit KU Medical Center and started private practice. Drop in revenue, everything and figure it out. Then a few years later, what happened was that we were in a hospital system and I was one of the persons really fighting for this with the hospital because our hospital got bought up by HCA and the value of how they were treating PM&R doctors and that they were taking all the social workers away was going to impact my outcome on the rehab unit. I said, you know what, I can't fix this. I've changed my, I was working on an MPH. I said, I don't need an MPH, I need an MHSA, Masters in Health Administration. And I started fighting for those patients. HCA wasn't going to change that. I said, thank you, I'm gonna give you my medical directorship, I'm quitting. I quit and we moved into a new building. I was twiddling my thumbs, no patience because you had a captive audience, I had no patience. And then I slowly built up my practice in outpatient. My advice to someone like you, that's a perfect thing. You don't know what you want to do, you have the skills to take care of patients. Start doing it, build up your reputation, get busy, and then start doing the things that you really enjoy. You just have to do the hard work. And reputation only comes with being in one place for a long time. I learned that afterwards. My wife was right, don't move, and I'm glad I didn't. I would, it's a very good question because I realize I'm very grateful to be where I am. You know, I have a situation where I didn't have the enormous debt that people do now coming out of training. I had some debt. But the first 11 years of my practice was in a situation where it wasn't entirely satisfying to me, so it did take time. And the other thing that I would agree with Dr. Patel on is reputation. You've got to establish yourself. That 11 years I put in, I earned a reputation in town. I thought I'd be in Houston a year. I've been there ever since. You know, I'm from upstate New York. I still consider myself a New York expat. So it's taken time. I probably live off my reputation. I don't do any marketing either. I just get referrals. Most of my referrals come from patients. I take care of entire families because they trust me. Part of the reason they trust me is because they know me. I'm not in the room five minutes. I'm in there whatever it takes. So that reputation helps me quite a lot. And around the community now, I have plenty of people that know me. So it sort of builds itself that way. But it came from putting some time in and then doing it well. Can I just add one more thing? Yes. It's a really, really nice situation right now. There are way more patients than physicians. And there are very few good physicians. Even the lousiest physicians are busy. So if you're good, you're gonna be crazy busy. And if you're super good, you don't know what to do with yourself, right? I'm serious. There's just way too many patients in any community. And if you're patient and you just sit in one place, the world around you changes. People quit, people die, people leave. Hospitals close, hospitals get bought out. Systems, all of a sudden they need help. If you're just patient and keep building up your reputation, then the job you really want, you may not even want it afterwards because it's not the right job. But if it still is there, you can then just move into it. Thank you very much for the answers. One more maybe suggestion, because you are teachers and teach students and everything. Is there, or are you thinking now as mentors to start some program through the academy to maybe present jobs and search for job, look for jobs, these type of lectures as the last year of residency for programs or medical schools or something? I think the academy as a whole is definitely considering, we've got a big investment, not only in residents but medical students. Partly selfishly, we want to build up the field, but two, we want to be available for the people that want to be us. So we want to give them the tools they need, and that is a commitment from the Academy of PM&R. Thank you. And we are looking, the academy is really looking into courses and things to help the person who already has a job but wants to move. Like the person, change, like the question you were asking. All of us now, you want to do EMG and nerve conduction studies. How do we brush up those skills and you can go back to doing it? Thank you. You're welcome. Hi, Marty Lanoff. I was the program, I was the public and professional awareness chair for six years, the marketing committee. Talk about a tough job. It's PPAC is the acronym. Just a horrible name, you know. We ended up spending probably about $100,000 during my tenure doing various outreach kind of endeavors. And one of the things we came up with or tried to come up with is, and leading into my question, we tried to get an elevator speech, just a one or two line way to describe what it is that we do, because I try to tell everybody that comes in the office. I learned that from Joel Press. Joel does that too. Everybody walks in the office, tell them we are physical medicine rehab. We are physiatrists. Unfortunately, it's really hard to do. And one of the problems with when we ended up getting some marketing place to survey a thousand people by phone after a whole bunch of money, and they came up with this elevator speech and it kind of died really quickly because there's so many different facets. We wear so many different hats and there's no one thing that can work for everybody. And we should have had the foresight to get five different ones for each subspecialty. But what is it that you tell people you do when you describe PM&R? How do you, what is the exact verbiage? What's your elevator speech, if I could ask? Well, my simple, my simple, I tell people, I'm gonna help you move better. That's what I do. You know, it's kind of concise in that, yeah, it's one thing if you've got a structural problem. I'm more concerned with how you move. I started a little bit different, even at parties and everything. I said, what does a cardiologist do? Takes care of the heart. What does an ophthalmologist do? Takes care of the eyeball. What does a PM&R doctor do? I take care of function. And what do I mean by function? Wherever you are, I'll get you, make sure you don't lose more function and get you better. And then I give them examples depending on who they are. And quickly, I just want to support, I had given a bunch of lectures on how to market yourself and basically it all boils down to be a good doctor, as you just said, John. Couldn't agree more. Exactly, that's the main thing. Be good, that'll take care of everything else. And I'll tell you, I'll be quite honest with you. I knew where I stood in medical school. I'm fortunate to have gotten through medical school. I didn't match residency right away. I didn't pass my boards the first time. And I'm doing okay. And the reason I'm doing okay is because I've given myself the opportunity to spend time with people. And that allowed me to make an impression on them that I cared. And then it gave me the opportunity to be able to do something well. Because I think a lot of people really short circuit themselves by just not giving themselves the time. And to me, being a good physician just gives, I feel like, one, I got to bring all of me to the job. And two, I've got to be able to listen and think about what I'm hearing. John, I think you're a late bloomer, that's all. I'll add just to that. Sarah pointed out some other things, and that's so important what you're just saying. When you're happy, you do a much better job. You take better care of your patients. And it just, it's a fulfilling thing, right? When you're not happy, you need to find out why you're not happy and get that, change that. Figure it out why you're not happy. Are you in a big hurry? You don't have, the patients are not scheduled correctly. Whatever it is, that little thing that's irritating, you fix it and then find out why. And then once you fix that, you start feeling better. Thank you so much for your presentation. At times, I've thought about starting my own cash-based private practice. And some concerns I have are the increased regulations around medicine and if I'm doing my own private practice, if I would be able to keep up with that. And then number two, if I wanted to go on vacation, how the inbox or coverage would work if I'm the only one. Because in this setting, it would be more similar to the just solo practitioner. So I was curious if you had wisdom. The first part, because it is tricky, right? I'm not in the office. I don't have anybody answering the phone. So I answer the phone here, I mean, as best I can. I'll try to get back to people. I'll return emails as best I can. And I make that apparent in my message when I leave. I'm gonna be gone from here to here. I'll do the best I can. And people kind of adjust to it, to be honest with you. Now, for years, I had somebody answering the phone and working in the office, so that's definitely easier. You don't have to do solo, solo. You can do by yourself with some help. That's up to you. This is the way I'm at, where I'm at right now. Tell me what you meant about regulation. I'm not sure I understood what you mean. And I don't necessarily have too many specifics around that because I've always worked for a hospital organization. So I would be concerned about making sure I follow the laws for Medicare in terms of billing. Well, if you're a cash vest, there's no Medicare to deal with. I'm not a provider. So you just tell people, you gotta make sure you tell people up front that you're not a provider, and they have to sign off on it. That's that. You're not a provider anymore. You don't have to abide by Medicare rules. Now, that's not to say you're unethical, but you don't have the same constraints. You do have to follow HIPAA and all that. That's something you need to do, but you're not bound by insurance companies anymore. Thank you. It's a great question, and people are thinking about it, and I don't do cash pays, but correct me if I'm wrong. Yeah, once you don't have to work with insurance, you don't have to worry about any of those rules. You have to worry about other rules like HIPAA, and then the other thing you need to keep in mind is malpractice and things like that, and then electronic medical records. They require all that, but you don't have to do that if you've got your own. You can take handwritten notes, or you can have an EMR of your own, a simple EMR. It really comes down to more of a business operation that way. Like, I have an EMR. I have electronic software. I'm in the midst of changing over because I feel like I need to do that. As far as billing and coding, I still code because I know that my patients may want to go after some reimbursement with their non-network benefits, which are not very good anymore. When I started, they were pretty good. People might get 50, 60% back, which then they're not really paying any more than what they would have with a copay anyway. So, I do what I can to help them in this situation. I also charge very reasonable rates. I mean, in the sense, I'm not billing just because I, or not charging just because I can. I try to make it fair. I think there's a question more for John about a cash-based practice. If you refer someone for a patient who does have their own insurance, and you refer them for an MRI or a medication that requires prior authorization, how does that play out for you and your patient? So, first of all, yeah, I mean, if it's out of my office, they can use their insurance. So, if I have to, most often what I have to do is send some notes to the radiology suite that I might use so that they can pursue that. It's not on me to get authorization, it's on them. They're the ones billing for it. I just help them out the best I can. On occasion, like, I might field a call, but by and large, I don't have to. Because the prior auth can take up a lot of office time. Oh, yeah, I mean, if I had to do that, I'd have to have somebody in the office. Thank you. I think we just have time probably for one more question. Go ahead, you're it. Sirs, just to follow up on the question regarding cash-based practice, would you be able to provide, oh, am I a little bit loud? No, you're good. You're good. Would you be able to provide insight on alternative payers, such as a concierge-based practice or industrial medicine, i.e., Workman's Comp? Are you asking me could I, how do I know? Would you be able to provide insight on alternative payer sources other than regular insurance, such as Workman's Comp or concierge-based medical practices? That's the ones where they pay a fee for access, and then, yes, go on. So I don't do concierge. It's pay-as-you-go. I don't actually like the concierge model, because what they're doing is you're paying up front for a privilege, it's kind of like a seat license, and then they're billing through insurance, right? So they're, you know, I get where they're coming from, but I didn't want to do that. I mean, I didn't want to charge somebody for just the privilege of seeing someone, seeing me, and that's a little bit of a risk. My primary care doctor does that. He charges, you know, I don't participate in his concierge service, but he has a portion of his practice where you pay up front to get access to him. It's not for me. What was the other part of your question? The other part is industrial medicine as a payer source. Oh, right, so now I am doing some of that, but I'm an independent contractor with the company that's sending them to me. So I work with a company in Ohio for either impairments, IMEs, I do a little, they also have an arm that works with the post office, so they pay me per exam. I don't have to deal with the workers' comp, which frankly, I hate. I think it's the most ridiculous system we have in terms of it. You're in Texas? Yes. Okay, I understand, cool. So I did, when I was younger, I tried to participate in workers' comp, and it was the most frustrating thing ever. You either get somebody who's completely trying to game the system or some poor soul that's getting victimized by the system, and you're trying to help, you know, trying to resolve either situation. It's very frustrating. What I'm doing now is basically a service for this company. I just provide them what they ask for. So it takes all that frustration out of it for me. Understood. I'll just make a couple of comments on the thing. The concierge thing really works well for primary care because you have a set number of patients and all that. It doesn't work for a specialist, I think, because they only use you when you need, and then it's a different kind of story. I think that's my take on it, because I've thought about doing that, but I haven't been able to figure out how to do it, so I haven't done it. And then the last thing with the IMEs and things like that, yeah, I think you just have a set, even if I'm in not a situation like John's, you know, the people pay. But what has happened to me, and this will sound really weird, but this in a way answers the question, guess what? Most people hate work comp, but a lot of people do it. Most of my work comp patients, I see very few, become my patients after the work comp case ends, and their family members want to see me. That is what I'm telling you is the secret sauce. Take really good care of patients. And I tell the patient, I really want to care for you. All I care about is you. I don't care about anything else. I'm gonna take care of you. And right now, what happens, my colleagues in town, the PM&R doctors and other specialists will see all spine, but as soon as there's a fracture of the spine, or a spinal cord injury, or a brain injury, it all comes to me. These become my patients. And why do I do it? My community needs a rehab doctor to take care of them. No one else will do it. And that's what you do, and that's how you build up a reputation. That's why, I mean, you brought up a good point there, and that's the way you do it. Take care of the one patient that may not even pay you, and you'll start having a lot of other patients, and do the things you really want to do. All right, thank you, everyone, for coming, and thank you, Dr. Sianka and Dr. Patel. Thank you, this is very enjoyable for me as well. Thank you.

sustainable practice

physician burnout

patient-focused

career paths

cash-based practice

ultrasound therapy

private practice

process efficiency

professionalism

patient care

practice growth