discussion today. It's a roundtable with myself, Dr. Taif McDomi, we got Dr. Marcus Harris, and then Dr. Junaid McDomi here. And we're all going to be sharing a little bit about a case study. And it's us starting a private practice. And this is definitely a unique venture for any one of us in interventional pain or in the neuromodulation society. And it's just something that doesn't quite happen that often. And we really want to share some of our findings, especially here over the past two years. All right, so we're gonna get started here. disclosures, none to report. Just a little bit about ourselves. And, you know, I'll kind of lead off just because I'm starting this and then I'll have our partners takeover. But my name is Taif McDomi. I'm an interventional pain specialist. I completed my medical school at Chicago Medical School up in North Chicago, did a transitional year at University of California, Riverside. It's an HCA location. And then I completed my anesthesiology residency at Brown University at Lifespan and then proceeded with an interventional pain fellowship at Hospital for Special Surgery Memorial Sloan Kettering Cancer Center and New York Presbyterian Hospital. And that was pretty much part of Cornell's tri-institutional pain fellowship. Guys, I guess I'll go next. I'm Dr. Junaid McDomi. I did my medical school training in Chicago as well. I went to Roslin Franklin University up in North Chicago. And then I did my residency at Cleveland Clinic in anesthesia, and followed by interventional pain fellowship at Rush University in Chicago. You're muted. You're muted. Oh, thank you. So my name is Marcus Harris. I did my medical school at Ohio State University. I did my intern year and in Riverside community. And I also did my anesthesia training at Sunrise in Las Vegas. And then I did my interventional pain training at University of Michigan. So it looks like we're still on the title slide. So I'm going to make some changes here. All right, so we just went through our title slides and our profiles, us three are all partners in the same practice. So we're going to share with you some of our findings and you know what it kind of takes to get started. And of course, everyone's kind of got their approach to this. And we're going to talk to you about what we've noticed and what worked for us. And then hopefully shed some light on more things so. All right, so. So practice types. So generally there are four different practice types. We've got academic, private practice employed, entrepreneurial, and independent contractors. You know, we can certainly talk about a few of these and I know a lot of us have seen some of these to some capacity. So from an academic standpoint, that's your classic teaching institution. It's largely salary or RVU based. You've got additional responsibilities aside from clinical responsibilities. So you've got your clinical responsibilities with seeing patients, but you may have residents, you may have didactics, you may have other obligations as part of the group. And those are things that you kind of have to think about for your, you know, future. So for example, it's university training program. So a lot of us who have gone through ACGME accredited pain fellowships or any other ACGME accredited fellowships, they may have something similar to this and that may be the only type of practice, you know. Beyond that, there are private practice employed positions. So that's your salary RVU based. It's usually a hospital system or a group or a private equity backed group. What does that look like? That's your HCA. You've got national spine. And then you've got other training programs within that as well. Sometimes they do come up with hybrids. Dr. Harris has been aware of that through his training and he could probably speak on some of that as well. And then beyond that, some of the things you don't really see are the entrepreneurial versions of your practice. So ground up operations, you're going to be involved with the clinical aspect as well as the administrative aspects of that practice. You're going to be really involved with the reimbursement collections because that's what kind of keeps your lights on. And then beyond that, you know, looking at other practices that do this really well. Arizona pain is a fantastic practice that used to do this a lot. I think it's kind of changed hands along the way. But it's definitely something they'll take a look at. And then you've got Carolina Pain Institute, which is a big practice out in Winston-Salem, North Carolina. And they've got a unique, you know, way of operating. It's certainly something you should take a look at at some point in your life just to see what else is out there. And then beyond that, you've got your independent contractor position. So a lot of those are contract based. You guys may see some of these jobs outside in practice where, you know, certain groups are growing. They're trying to fill a need and they just need you there for a short time to kind of build that growth or someone's taking a break, they're going on vacation, something else may be happening and you're filling out the void. So you can see that in any setting. You can see that in a hospital, you can see that in a clinic, you can see it in a private group. You know, there's a wide array of things you can get into. Now these aren't like cut and dry. It's really a spectrum. You might find, you know, components of each. We've definitely had colleagues across the country who have gone into an academic setting that's under a university and then kind of get all the tools in place to kind of build their own practice. So you really got to figure out like what are the pros and cons for doing each and every one of these things. And then what suits your lifestyle better, especially outside of training. Us three, we started right outside of training. So we kind of had an idea of what we wanted to do and explore. And that's what we spent doing. Do you guys have anything more to add on that? I mean, what do you think about this, Dr. Harris? Yeah, I totally agree. I think the biggest, you know, point to all of this is you got to find what's going to fit you. And, you know, it's a cool cashy thing to be like, hey, I'm going to go and, you know, take an entrepreneurial route, but that might not be the best case for you. That might not be what you need at that time. It might be, okay, I'm going to go academic, get my feet wet, get kind of grounded, get all my skills up to that level that I need to be attending. And then, you know, I'm going to pursue maybe an entrepreneurial or go into a partnership later. Or you might want to look at like, maybe I want to do independent contracting. If you had training in PM&R or anesthesia or another specialty, you're working more on that. And then you're still maintaining your skills by filling in and picking up cases here. I think the big thing is, is really looking within and figuring out what works best for you, especially coming out of training. What's your goal in the next five years? What's your goal in 10 years, 15, 20? And those things will change as you kind of go along your path. And so as you go along that path, you'll figure out which practice type fits best for you. And, you know, looking within is the most important thing because a lot of times you think, oh, this is cool. I need to do this route. But no, I mean, if it's being in an academic setting, having that kind of like support there, that's perfect. There's nothing wrong with that. That's a great job. And I know a lot of great physicians that are in that model. So I think it's an excellent choice. But if you want to go out and kind of take that adventure and be like, look, I'm going to go out and try to, you know, make my way and make my path and take an entrepreneurial route, that's also great. So it's really just looking within and seeing what's going to fit you best for the stages of your life as you kind of come out of practice. And this kind of goes in tune to as well. Like, you know, you don't have to be just out of training and thinking about this. You are always thinking about this. You know, there are individuals that have been working a certain job or certain setting for five years thinking about the jump. You know, in our area, Columbus, Ohio, we had a previous chair of a pain department jump into private practice. You know, this, these things do happen. And you just have to be aware about what all is happening across the board. And the big thing I would mention on top of that, too, is, you know, given time, there's going to be a time where I am not going to know enough about what the academic, you know, space is going to look like or what the private equity space is going to look like, because that's not my practice. And a lot of times just talking to the certain people that are in those industries, that's where you're going to get the most information. I rarely ever ask for advice from a private practice standpoint from someone who is not in private practice, because they just don't get it. It's a completely different model. It's a completely different thought process. We are taking clinical decision making outside of the, you know, conversation when you're thinking about some of these practices, because it just doesn't match up the same way, depending on your, you know, your setting. All right. So what are the styles? You know, there are many styles or types of practices you can have. A lot of times, like I said, it's a spectrum. So it may be a combination throughout these. Largely, one of the big things that tends to get overlooked is medication management. Medication management in the pain management space really varies based on what type of practice you're going to have, if you're going to be managing any controlled substances or not, and then determining what type of regulations or compliance issues you may come across. That's something that nobody can really answer for you. That's something you have to decide on your own. There is a huge opioid epidemic that we all as pain physicians have been kind of, you know, navigating. And fortunately enough, there is a space with neuromodulation where you can address a lot of those constraints with opioid prescribing practices. So that's still, you know, a part of pain management, just understanding that, you know, beyond just the interventions, there are other things out there that you need to be aware about, be familiar with, and be able to provide for your patients. Beyond that, you've got your interventions. So in an interventional practice, whether it's procedure-based in the office, ASC, or hospital, you need to understand what our views mean in this setting. It's not necessarily for you in private practice, but regardless of what your contract or what your future may be like, it's all going to be based on production and understanding production models and where it makes sense or it doesn't. This goes into play with when you're looking at contracts as well. And it's definitely something you need to spend some time understanding. And hopefully your fellowship programs talk to you about that. If not, you should definitely reach out to colleagues. You know, we are definitely available as a resource with this. Beyond that, surgical. So it is the hot new thing in pain management or interventional pain where people or physicians are in the surgery centers, whether it's an ASC or a hospital, and they're bridging the gap between injections and major surgery. There's a tremendous amount of opportunity in this. And then whenever I talk about opportunity, I also talk about risk, right? So you got to stay in bounds of what's appropriate, what's within your wheelhouse, and just understanding those limitations. Although we are pushing boundaries, you got to remember, and I think I hear I heard this throughout my training, like, you don't want to be the first person. You don't want to be the last person either. And just trying to get a feel of the temperature of whatever new interventions or new things are out there, and just make sure you're safe about it. And then the last step would be regenerative. So it's largely cash based. It's not really insurance reimbursed. You've got your prolotherapy, PRP, BMAC, lipogems. There's a lot of, you know, things coming up in this particular space. And, you know, we definitely get approached by a lot of companies in this space too. And the big thing I'll tell you is compliance, right? Historically, there's just been a lot of instances where things didn't pass the sniff test. And as private practice physicians, we are the ones that are making those decisions. So really understanding what that means and what you're getting into for this. Dr. Junaid, do you have anything to add on that? How do you feel about that? I know you came from a largely surgical practice. So maybe you could shed some light on like what your transition was like, leaving that and kind of starting from the ground up like we did. I think it's just really important to kind of keep an open mind. You know, where you train and how you train in that practice setting isn't necessarily where you're going to go train afterwards. But you always want to kind of be able to adapt to the situation. So we did a lot of things in the surgery center. So we had a lot of anesthesia available. Patients were sedated for a lot of procedures. And then I moved out completely to an office space setting. Right. And so now we're thinking of how can we treat these patients more comfortably. Right. So we're using smaller needles. We're doing things, you know, we're paying really close attention to how our patients are dealing with certain procedures. We're talking to them during the procedure. So you kind of always want to keep that fluid, the fluidity available for you. So you say you're not stuck in being able to do things just one particular way. So I think that that was kind of one of the biggest transitions for myself is, you know, going from a surgery center to do and predominantly office space procedures is a completely different flow and just being able to adapt to that. But, you know, like you said, I think that you just got to always be up to date on just how things are going, you know, understanding compensation models, knowing what's a professional fee, what's a facility fee, am I getting, you know, what I'm supposed to be getting for the things that I'm doing. So a lot of people don't understand some of these things and they leave fellowship, they take a job and, you know, they find out a few years later that they just weren't getting compensated the right way. So I think, you know, all these things play a role eventually, especially once you go out into the real world, because there's nobody here. They're holding your hand anymore. It's, you know, fellowships done. You're just a colleague. Now you got partners, you got to deal with your, you know, how you deal with that. So All right. I think fair point. You know, I spoke to a colleague about starting a private practice about a year ago when we're in the midst of this as well. And, you know, you're starting your own private practice. What, what does that look like? Right. And I love this quote about this, you know, if you want to go fast, go alone. If you want to go far, go together. And really speaks about our practice because, you know, we come from three different backgrounds of interventional pain training. I learned something every day from Dr. Harris and Dr. Junaid McDommie. And then we, I'm fortunate enough to even share, you know, my knowledge and my experiences at my three, it's the three hospitals that I get to spend time to. So, you know, we were all fortunate to get different flavors of interventional pain. And really, my practice has grown tremendously just from being around these guys. And, and I think it's really hard when you jump into a job that you may not get that type of environment. And we really did it from the ground up. We were able to cater and craft what our practice was going to look like and how to build it in Columbus, Ohio. And I'll talk, we'll talk more about why Columbus, Ohio. And, you know, what, what kind of transpired during our time. But I'd say the number one goal for building a practice is starting off with a foundation of healthcare compliance. You know, I wrote an article about this previously. And like, you cannot start a private practice nowadays by just opening up an LLC or hanging a shingle and doing, starting from scratch. Healthcare is not like it was 20 to 50 years ago. It is regulated. If you follow hospital systems and in general, they're getting, you know, having to deal with regulations, fines, you know, staying up to par and private practice is no different. And that's what's the direction of healthcare. And really just tapping into that because that is not something you've learned in your medical training at all. Yeah, I'll kind of, I'll kind of like piggyback on that. So I think that the compliance aspect of it is something that many of us may be just overlooking, you know, this is a big part of pain management, especially in a private practice setting. Because, yeah, if you're doing this on your own, you're going to have to figure out the pieces on your own. So you got to know the state laws. You got to know the county laws. There's a lot of ways that you could get fined or things that you may be doing that's incorrect just because you didn't know or you're not aware. And so we spent a lot of time trying to figure that out, you know, our first year of practice and pretty much getting the right things in place. So, you know, having a lawyer that you can, a healthcare lawyer is going to definitely help you to set up the compliance plan and, you know, appointing an officer and kind of doing quarterly reviews about, you know, what issues are we having? How are we addressing these issues? You know, and having everyone be able to have an equal voice and state issues or concerns that come up. So I think that this might have been overlooked many years ago, but it's now becoming, you know, even more important than it ever has been. And so I think that we've spent a lot of time trying to incorporate that into our practice and we'll continue to refine that as we go. Yeah, and I agree. And I think the good point that he also brought up for everybody just to pay attention to this. So there's going to be federal guidelines that we have, but there's also very specific state guidelines. So your state can be different overall. So you might think, oh, I'm following federal guidelines, but that might not actually qualify for what your state is doing. So that can be an issue too. So really understanding not just the federal guidelines, but your individual state in which you're working in. What are those guidelines when you're going forward trying to start a practice? And that's just the regulation part. I mean, we have clinical guidelines as well. So on top of that, you have to stay on top of like NAC guidelines, particularly for neuromodulation, right? And just making sure whenever you offer these types of therapies, you're aware about those guidelines. So it's really just about understanding compliance and regulation. So my chairman at Brown would always say, you know, vision is the most important part. You know, and that I could not agree more. You have to have vision in this space. You have to have vision about what your practice is going to look like and what your life is going to look like. You know, if you don't know where you're going, any road will take you there. And that's a big thing in private practice, especially if you're starting from the ground up. But even in life, you should have some sort of vision or expectation or plan for what your life is. And this circular, you know, diagram kind of shows that the start is planning. We spent probably a year before doors open planning. And you could probably say you can cut it shorter. We probably could have used a little bit more time when we look back on retrospectively, but you also need to pull the trigger at the same time too. And, you know, planning is the most important part and we plan, plan, plan. We did a lot of homework and we'll talk more on that. Beyond that, you know, Dr. Harris does a really good job and he can probably talk more about this down the road, but building your team. You guys start with your essentials and then build from there. We did some things a little backwards, but we knew what we were getting into. I can't tell you how many physicians I've talked to that kind of say things like, oh, we're going to figure it out. Or, yeah, I'm just going to try it out this way and kind of see how things lie. And that's how you get into deep, deep hot water. You know, a lot of people that are in private practice, you know, or so I'm told that, you know, they face challenges every day and just having a good head on your shoulder and understanding about your past, present and future and what you're expecting is super important in this space. Health care changes every year, CMS guidelines and CMS reimbursements change, what you get paid for X, Y, Z changes, what things are even approved changes. So, you have to be nimble and you have to understand what types of changes could be on the horizon, and then adjusting to that. And then execution. I mean, you know, people have all these like golden goose ideas. Just because you have an idea doesn't mean you're going to execute well. There are plenty of ideas that we don't even know that weren't executed well. So, really just trying to sort that out is super important for this whole prep, you know, this whole thought process of building your practice. Dr. Harris, you have anything to add on that? I agree with, you know, kind of everything you said. And I think another thing that people got to look at, even with the perfect planning, you got to be able to adjust on the fly. So, you know, you might have everything laid out and you think it's perfect. And then once you get in there and you get in the game, you know, you have the first scripted 15 plays of the game and they come out and show you a different look and it's like, oh, we're gonna have to adjust to that. And I think that's the biggest thing. So, you know, there has to be a certain level of malleability to what you're doing. And you have to be able to adjust to things on the fly because you have things planned, things change. And in those changes is how you react in those moments that usually leads to better success. And so, that was something we learned along the way because, hey, we laid it out. We probably talked about it for a couple of years. And then once we got in there, we saw some things were a little bit different. But we made the adjustments that we needed to, you know, push forward and have some success. So, we got some questions in the audience and I'll definitely address that. One of the questions from an attendee was, do you think in your experience that it's naive to think in fellowship, we know what practice style we want? So, I can chat on that real quick. You can obviously know what kind of practice you want, like you're going to get in there and by the time you're done with fellowship, you're going to know like, I like this, I don't like this, I want to do this, I don't want to do that. Fact of the matter is, it just depends on where you end up. You know, Dr. Junaid McDomi can probably talk on this a lot more. He went to Rush. Rush is largely ASC-based. You're doing surgical procedures. It's a primary admitting service. He was doing so much in terms of hands-on. We get into Columbus, Ohio, and we're in like one of the ground zero states with the opioid epidemic, you know? So when you talk about implanting, you know, therapy devices and things like that, wait a second, we're still dealing with things that maybe, you know, my training in New York City, they didn't see, you know, 10, 20 years ago, and we had to adjust. And you have to decide, do you even understand the market well enough, right? What the practice that we have in Columbus, Ohio, is it going to be the same practice had we been in Miami or Los Angeles or Kansas City? Probably not, you know, every city is gonna be a little different on that, and you just need to spend the time to understand what that looks like. If you're gonna practice in the city, you're doing fellowship, then great, you're gonna probably have a good understanding about what the practice is gonna be like in your area. If you're trying to go somewhere else, you're gonna learn real quick whether or not you're gonna sink or swim. I'll tell you, there have been other practices that have started in Columbus, Ohio before us, they're not here anymore, so that does happen. But you just have to do your homework. Like I said, there've been so many people that don't do their homework and think they'll figure it out, and this is not one of those things, you just can't do that. I think one of the best things you could probably do is pretty much adapt to kind of any type of pain styles, right, so, you know, understand all your different treatment medications, right, your antidepressants, your antipsychotics, right, neuropathic medications, and then your interventions, right, so you don't, you know, you never know what kind of environment you're gonna be in. You might have patients that, well, don't want any type of procedures, but you're trying to help manage their pain and you're trying to do, you know, other methods other than opioids, so just understanding your treatment modalities and how to use them, how to titrate them, you know, I think that's gonna be, that's gonna go a long way, because if you don't know what type of practice setting you're gonna get yourself into, you know, if you're a, let's say you train completely interventional and you didn't get any of the management aspect of training, you know, it's gonna be very tough if a lot of where you're at doesn't have that or they're not looking for that, so, you know, being able to adapt to that and being able to just provide the comprehensive care, yeah, it can make you more versatile depending on where you end up. So a few other questions. Did you ever consider using a consultant to start a private practice and which company did you use for insurance rate negotiation? Dr. Harris, did you ever consider a consultant when we were starting a private practice? Um, I did not, but that might've been a little bit of the arrogance that comes with being me. I thought between, to me, I thought the biggest thing when starting a private practice, especially as we talked about, we talked about you go farther together, it's making sure I had the right people. So, I mean, that was really the biggest thing, consulting to make sure I had the right partners where we shared a vision and they were detail-oriented and they knew we needed to like lay out step-by-step how it was going to be done. Like, how are we going to go forward? How are we going to make this plan? How are we going to get from A to B? If I was talking to somebody and they're like, hey, I want to go A to Z, but they forget B, C, D, E, F, G, all the way in between, that's not going to work. And so the one thing, you know, when I talked with both Dr. Junaid McNamee and Tyke McNamee, they got A to B, they got B to C, they got C to D. And so those steps made it to where I could see how we could build and how the practice could grow from start to, you know, being at our, almost our two-year mark and having, you know, a level of success that we wanted to see at this point. So I think I never thought about having a consultant, but if you're with it and you don't understand how to go from A to B, B to C, there's nothing wrong with reaching out to somebody to help you to kind of get your practice started, who has some ideas and things like that. Knowledge is a big thing. We still were communicating with a lot of different people. I was asking a lot of people questions. I talked to multiple people around the country who have their own private practice. I talked to my attendings and fellowship about how to go about things. So you're still asking questions. You're still reaching out for knowledge. Do you necessarily need a consultant to come in and kind of show you? You know, I might not think so, but also if that's something you think that would help you get to your point and get to the point of opening up your own practice, I'd say, yeah, go for it. But I do think if you do your homework, I think you're able to do that without having to pay somebody a consultant fee to get yourself started. So that's my opinion. And to kind of piggyback on that, I think that what Dr. Harris was saying is very important because if you don't educate yourself on how you're gonna get from A to Z, how can you really know if the consultant's giving you the best advice? I mean, you have to know exactly what you're doing and how are you gonna get there. No one's gonna be able to do that better for you than you. And so really, I think that knowledge is power and educating yourself on that, it's probably gonna pay out way more than paying money for a consultant. I'd probably say we all, all three of us know at least every step of the patient journey, every step of the financial journey, every step of the treatment journey. I think we're also fortunate enough, if you're in fellowship, ask questions. You're sitting there with MAs, you're sitting there with billers, you're sitting there with people in the front desk. You don't only learn from your attending physicians, you're learning from everywhere and everything around you. And you need to start opening your eyes if you're not doing that yet, because I learned tremendous amounts from my peers that way, top down. So you definitely have that opportunity. We have another question about which company did you use for insurance rate negotiations? So we actually didn't use a company for negotiations. We're actually getting approached right now by a few consulting companies to renegotiate some of our rates. I'll be frank, when you first start, it's all about just getting started and getting moving. Whenever you meet with these companies for insurance rate negotiations, they're gonna ask for fees upfront, they're gonna ask for payments down the road. You don't even know what your future is gonna look like. Are you gonna be above board? Are you not? Why not just start and work on that, work on your clinic and see what your clinic grows into before you start spending money on things that you don't necessarily know it's gonna work out. And then I'll tell you the other thing, we only have upside. We renegotiate our rates, it's only upside from where we are. So we're not starting at the bottom, or at least further down from the bottom when we go up from there. There's a few other questions I'll get to along the way. We definitely can talk about it on the slides. But going back to just creating a timeline and expect a one year out from initial work. That's our personal experience. Other things to think about is choosing your opening date and creating that deadline and just be ready to go. That's what puts the fire under your butt to get going and get what you need to do. One of the key things to think about is where do you wanna practice? One in five Americans suffer from pain. Pain's the number one reason people seek medical care. You all know this, whether it's surgery, pain management specialists, neuromodulation specialists, all of the above. There's one pain specialist for every 27,000 patients in the US. In our particular area in Ohio, there's one pain specialist for 80,000 patients. We are such a hot commodity. I can't even tell you how much enough. People think, people tend to wonder, oh, am I gonna get a job? And we really should be changing conversation and being like, where am I gonna get a job? Who's gonna be lucky enough to have us? Because we are needed. I can't even tell you how much we are needed across the country. And then beyond that, 40 to 60% of patients report unsatisfactory care. You coming out of training or you young in your training, you wanna get out there and help people. You haven't been jaded over time. You haven't been dealing with certain challenges throughout. You're young and you're ready to go. I mean, that is opportunity because I'll tell you, some people, over time, it's just a lot and it takes a lot out of you and maybe things don't line up the way you expect them to, but this is your chance to kind of shine and make something of yourself. And then this is something we'll probably see for a longstanding time is just PCPs are overwhelmed and ill-equipped to manage pain. It's just not part of their training. They're managing so many other things and you really just need to be out there as a resource. I'll tell you, like the things we've learned in the past two years is people are happy to know we're out there. People are happy to send patients to us. People are just happy to know that there is other options outside of whatever's in their wheelhouse that we may be able to provide. So I talk with Dr. Harris about this a lot. You know, when I called, when I was calling around and trying to figure out what's going on in Columbus, Ohio, the biggest thing I heard was the market is saturated. And had I not done my homework beforehand and talked to people in this area, I would have known, I would have been like completely distraught or not, you know, concerned about even starting up a practice in that area and bringing in two other partners or even talking to two other partners, say, hey, I've got this great idea. Let's come here, Columbus, Ohio. Well, you know, if someone tells me, if someone who's been in the industry is telling me the market's saturated, that's just not something you wanna hear. And I don't forget about these things like that. You don't forget about a lot of this stuff when you start from the ground up and you just remember it kind of throughout the way. And I'll tell you, like, I don't think there's any city that is saturated. I think you have opportunity everywhere. The caveat is, can you weather the storm before you become relevant? I don't know. Everyone's a little different and that cost tends to change based on which environment you're in. Yeah, what do you guys think about that? Yeah, I mean, so I think this is a big thing too with everybody and this goes from when you're first coming out of school to if you're 20 years in, yeah, it's not saturated. So don't let anybody tell you that because what that's doing is demeaning your value. And so you gotta know your value as a pain physician. And there'll be, whether it's, you're working in a private practice and you have somebody, what base and your contracts, know your value because if you know your value, you will find a job, whether it's academics, private practice, whatever, and you're gonna get the compensation you deserve because it's not. There are a lot of patients who need pain providers. This is just facts. I mean, we see it every day, even when we think, hey, it's gonna slow down, like two years in, we were new, maybe it's gonna slow. No, it doesn't, it's actually picking up steam. So I think with knowing that and seeing that, it's important to know where you're going. It's just gonna change, like you said, how quickly can you reach certain heights? How long can you weather that storm? So if you're in a New York City, you gotta put into all the costs that comes with that with being in New York City and running a practice. So how long can you weather that versus if you decided like, hey, I'm gonna go to a rural area. Well, you probably can weather that for a long time, depending on how much you're coming in with. So just looking at those things, just remembering that, like remember your value is high. Don't let anybody tell you differently. Always read your contracts. Your value is high. There's a lot of patients out there and they need to see you, so. And yeah, I mean, I think that the other thing is referral networks. You know, that becomes very, very important. And you'll start to realize every city has kind of a pattern, right? They have major hospital systems. They have certain insurances that you're a network with, you know, and they kind of just feed the system. So the question is, can you break that system or what makes you different, right? Maybe you can see patients sooner. Maybe you have more providers available. Yeah, so there's a lot of ways to kind of get into that system. The question is, you know, time. Time and availability, putting yourself out there, letting people know that you're there, how you can help them, how you're different. So making yourself unique in a city or having a niche practice or having different partners that specialize in certain things can also at least give you more value in the city that let's say is saturated. So I think that just keeping that in mind, there's always some opportunity available. So a few questions in the group here. How did you market your practice and bring in patients slash referrals? So we got done with training June 30th. We were in Columbus, Ohio by July. We didn't open up our practice until November of 2022. So we've been under two years in now. I'd probably say from July to November, all three of us were at clinics, building hype, talking about our practice, talking about when we're opening, talking about all the services we offered. We were meeting people left and right. I couldn't even tell you how many meetings we went to. It kind of seems surreal. And it was a great experience. You know, it's funny. We look back and we're like, man, that would have been times you would have enjoyed had you known like the direction you're moving. And that's exactly what happens in this type of space. Like we all have said, there's a need for you. You just need to talk to all the people who need to see you and who do you think are gonna be good referrals, right? A lot of times, if you're learning about this from the start, you really just talk to your attendings. I can't tell you how many, one of my attendings, we were chatting and I went next door and talked to like one of the dermatologists and I was like, hey, do you see so-and-so condition? They're like, yeah, we don't know what to do with them. Well, can you refer it to us? Because we can help you with it. And it's neurogenic itch. And I brought it over, I talked to my attending and we started seeing patients from dermatology for neurogenic itch. And it's just such a unique thing that you wouldn't think about unless, you know, you thought about the pathophysiology of that specific condition and how you can help other specialists with their patients. Cause they're definitely seeing that. The other thing was, did you guys ever consider buying a practice? I mean, what do you think Dr. Harris? Yeah, I think for us, you know, the main thing it kind of goes back to, you got to look at what you want out of a practice. So I had my vision. So when you buy a practice, you got to think somebody came in, they set the vision, they set the way and now you got to bring those patients in and they have a certain way where they want things done or they're used to having things done. So for me, I always thought starting one for my own from the ground up, we can kind of set the foundation of how we want our practice to be ran and the patients we get in and they kind of go through that kind of builds that culture. Because over time, what happens is there's a culture that comes. So it's different. So they know when you say pain zero in Columbus, Ohio, they know what that coach, they know when you say Tyke McDonough, they know when you say Janae McDonough, they know when you say Marcus Harris, what the expectations are when you come. So patients are already telling me my spiel before when they come in the room. I already know Dr. Harris, this, this, that, I don't have to say anything. I'm like, great, you already know what the deal is. So let's go, what's rock and roll and what gets you feeling better? So to me, I felt for us, no, I knew we were going to be, I always wanted us to start it ourselves from the ground up because I wanted to set that foundation for how the practice was going to be ran. I didn't want to take something and try to have to mode it or hybrid that thing because I felt if you're going to do this, you got to have that vision, you got to have your direction, how you want it to be ran and you got to go execute it, so. Great, fantastically said. All right, so we're going to move on with our slides here. So you found your location, so what's next? So you got to establish your executive team. You got to find a business lawyer. It's usually contractual, help them like set up an LLC, articles incorporation, if you want to do any bylaws. I mean, you can't mess around with this. You can't do it yourself. You know, we knew from the ground up, we weren't going to do a mom and pop shop style on this and you really can't do it anymore because healthcare is not like that. So you really need to spend the time and build it like you would any other big time business or what they would do, right? Coordinate with a business CPA. So tax planning and preparations, it's so huge. You need to understand that. You need at least to have one on like speed dial that understands what you're doing. Bookkeeping services. So that's a little different from a CPA. That's basically your monthly, yearly transactions, how, where things are, where money is moving and how to best, you know, make adjustments if you need to. Enlist with a credentialing company. So RCM or PA specialists, like we have, you know, in the less than two years we've been together, we have interviewed probably 10 different RCM companies, revenue cycle management, just for those of you who don't know we've been with one, we switched within a year to another one. And the one thing you realize throughout all of this is everyone's trying to sell you on something and it's just trying to tease out, you know, if what they're selling actually matches up to what you need and what you need to get delivered. And you really need to be compliant in terms of evaluating that on a weekly, monthly, yearly basis. Otherwise, like I said, you're gonna lose money and then you're just gonna be out of a job and out of the business. You know, Dr. Junaid McDomi spoke on this, getting a healthcare attorney, you know, that's super important because it's a space you don't know. You know, if you don't know anything cardiology related, you go seek a cardiology specialist. Same thing here, like if there's something that's outside of your wheelhouse, do not try to figure it out yourself. Be aware about what it is, but go to a specialist. Lending options, you know, physicians are high paid individuals. So figure out what type of lending options are available in your area, what type of grants are out there. Are there grants for minority business owners or women business owners? Because there are, I'll tell you. Malpractice, malpractice is another thing. Usually when it's your first year out of practice or first few years out of practice, you get a ridiculous discount. Like all your employers, whoever hire first people out, they get the best discount of their lives because you have a clean record and malpractice is so cheap. And this is the time to do it when you're first out because afterwards that malpractice doesn't get cheaper. It may over time. And then the other thing is you just gotta be careful about what you're getting yourself into. Identifying office space. So that's another big part. Do you wanna sub-lease? Do you wanna go into a clinic that's already functioning and work out one day, two days, a few days a week? That happens. Do you wanna lease? Do you wanna lease a space for, you know, usually commercial leases or three to five years and then that's buying you into that place. Most people start at that and then they lead towards like, hey, we need a bigger place or hey, we might need a smaller place. And then sale, right? Do you wanna buy a place and really go all in? And it really just depends on your market. You know, you can't really buy a place in New York City right off the bat. I mean, some people can, we probably couldn't. But these are things just to think about because if you're in the middle, you know, of rural area, you could probably find space pretty easy. And then just understanding there's also different changes in the market with that, right? Construction stuff and how is it hard to fix or mold a place to your specific needs? So just being aware about that. You know, I can't harp on this anymore. Study your market and build your community. AAMC has data. I think it's up till 2022 now where it tells you like, what is the percentage of this particular specialty in this particular state? The other great thing I love in there is how many physicians are over the age of like 60 or 65? Because you already know those doctors are not going to be there five, 10, 20 years down the road. So that means what do you think is happening through their practices? It's just not operating the same way. It's not continuing. There might be areas where, you know, someone mentioned buying a practice, but then when you buy a practice, you got to realize, and you can see this with buyers across the country, they're not buying from other doctors anymore because what happens is the doctor retires. So let's say it's Dr. Harris. I bought a practice from Dr. Harris. Dr. Harris retires, and now they're stuck with Dr. McDomi, and they don't know Dr. McDomi, and they're going to start looking around because it doesn't matter if they saw you and liked you, or they want to see what else is out there. There's no difference between that because you're not Dr. Harris. So you got to remember that that's not the same thing. And the value of that is not the same. So a lot of older folks that have practices, they're trying to, you know, they're getting into retirement age, they're like, hey, I want to lose, you know, I want to sell this practice, what do you think? That number doesn't translate the same way. And you may not know that. But that is the reality. And that's why they're not getting bought up a lot of times. So just being familiar with that. Most of the times, if those situations do occur, you have to be there for another, you know, two to five years to usher a transition period. But even then, it's not as easy as you think. So just being mindful of that. So hardware, you know, a lot of this stuff's like listing off things that you need, you need an ultrasound, depending on your training, some trainings are highly fluoroscopically managed, we had a combination of the two. But I think it's becoming more mainstay that you have both ultrasound and CRM, butterfly v scan, Clarius, those are all those portable ones. Or if you get like a refurbished GE, I'll tell you, we have both, you know, I like certain aspects about the portableness of, you know, some of those portable devices. But I also like the tried and true ultrasound. So whatever you're more familiar with, we did a lot of shopping on eBay. And you can get a lot of good stuff there. So definitely keep that in mind. CRM, there are plenty of companies block imaging is one of them you can rent or own or rent to own. GE does it as well, but tends to be a little expensive. And then you got to figure out which one you want to go with, right? We love GE. It's just like one of those tried and true, but you've got plenty of other, you know, brands for CRM, Siemens is one and things like that. So, you know, there's plenty out there. medication cart, so you got to you got to buy medications. So you got to figure out where are you buying it, where you know, one of the things you realize is when you're in fellowships, like where's everyone getting this, and you might see things like McKesson, Henry Sheen, like, Cardinal Health, like stuff like that. And just figuring out how do I get those conversations? How do I make that happen? What do I need to order? And then beyond that, it's just pain, their pain supplies, you got to get needles, RFA needles, numbing needles, drying up needles, you know, syringes, all the above, like you need to go start searching for that. And with that being said, there's a man's seminar that talks about GPOs and all that, and you should listen to it and just try to figure out what's your best way to do it. We definitely got involved with their GPO. And, and we're, we're extremely happy with it. So furniture, it's like the waiting room furniture, exam room furniture, procedure room furniture, again, you know, eBay, Amazon goes a long way for some of this stuff, or you can just start going straight to manufacturers that work with medical supplies. Again, just depends on what your budget is and how much money you're willing to spend. You guys think I missed anything? Yeah, and it's, you know, even when we went to the furniture store, and we like saw those like good chairs and everything. So I was like, Hey, what is this pretty good? Good stuff here. So yeah, just open to kind of multiple places to kind of find yourself and especially when you're, you know, with a budget. So yeah, we I think another thing to really just keep in mind is, you know, you're the opening cost, the cost to start up the practice, right, that can be very variable, even if you think it's going to be X dollars, you got to plan for, you know, plus or minus 2030%. And so that, you know, one of the things you got to think about is, well, at first, A, do I have enough money to do this? Or B, if I don't, do I have money coming in somewhere else to where I can make this happen? Right. And so stay in a float. And so I think that always kind of think about that, because you never know if what you have is going to be enough. Obviously, the more you have, less stress, you'll be about it. But you also want to make sure that you're able to pay your employees by all the startup necessary costs, and you don't want to skip out on the important things at the same time. So software, you know, we did, we spent a lot of time on software, you know, being a newer generation, you're not your classic, like, you know, pain physicians or, or surgeons that are in their like 50s, 60s. We're very tech inclined. So our website's SEO optimized, we spent, we contracted with a company that that's all they do. So that's what we wanted to do, we needed to be really good at that. Our EMR, you can get have your choice, you can have a, you know, broken, trimmed down version of Epic, if you really like Epic, we use eClinical Works. And that's largely because Rush did a lot of that. And Dr. Junaid had experience with that. And we're like, hey, you know what, let's just use that. And it paired well with everything else that we did. Athena, Dr. Crono, I mean, there are plenty of options out there, you just want to go with what you feel most comfortable with, and then what is widespread. I know there's some niche EMR, you know, programs out there, but you don't know what you're getting into. And you're it's better off suited to get something that's a little more mainstream. Marketing SEO is huge. We definitely capitalize a big part about that. I think we rank number one, or on the first page for pain management in Columbus, Ohio. So that's been really great. You know, when I talked about community back then, you know, we know a lot of the physicians in the area, we meet, we've met all the pain physicians in the area, we send patients back and forth, it's a very collegiate type of environment. And we're happy to do it. And it's just creating that type of environment for you. So you just got to make sure we're all in it together. And there are plenty of patients out there, there really are. There's no need to get worried about things like that. Brand company. So there, I've been seeing a lot of branding companies that take physicians and kind of make them into their docs. And I've just never really been a fan, you have spent hundreds of 1000s of dollars into your education into building who you are as a doctor. That's the value of you, right. So when you go to a company that says, hey, I'm going to manage your brand and build your brand, and you'll be one of our docs. You just got to remember, that's that's taking a piece of you because you're the high value target here. It's not the other way around. And a lot of times, we as physicians, we come out of training, and we just don't know, we're like, hey, we're happy to be here, we're just wanting to be a part of this. And, you know, you just got to realize that you're you are one of the most valuable things out there in this space. And just understanding that and realizing what that is. Social media, and social media is great. I see a lot of stuff on that Dr. Harris can probably touch on that. But I'll tell you in Columbus, Ohio, there have been some people that have gotten into social media trouble. And you just need to understand what that space looks like. And do you want to take that risk? Because sometimes it might be worth it, but you don't know what's around the corner. And you don't know what you're getting yourself into. I don't know that well enough either. And it's probably better to talk to those people that are in that space. You know, Dr. Harris and I are fortunate enough to know, you know, a few people in that space. And we can talk to them. But at the same time, there's always pluses and minuses for all this. And then beyond that mailers, you know, we're in a small big town. So we actually sent out mailers, and they seem to do pretty well. So trying to figure out what your strategy is, and how you're going to get in this area. And, you know, I speak about this, because specialists are, you know, they could be six to nine months out. So you might have there's a guy out there that's looking for XYZ therapy that has to wait six to nine months. And you might be starting a practice, you could offer it that same month, you know, or the same week or whatever, they just need to find you. So they're definitely out there. And then VOIP communication. So like our phone lines are all digital and have metrics and all that stuff. So that's super important with your software. Dr. Harris, you want to talk about staffing? Yeah, this will be kind of so staffing, this is, um, I think one of the more important things that you can do with staffing is, you know, the biggest thing is putting the right team together. And so when you're putting a team together, the big thing you got to remember with that team, if you want to level continuity, the toughest thing about this is change is going to be detrimental to your program. So when you hire, you got to look at the person you're bringing into your practice. Not only are they going to fit your ideologies, but do they have a passion for what they do? Do they have a commitment to certain things that they want to do in life? And then are you going to give them the opportunities to grow? So, you know, my big thing that I have every person who I like to bring in is okay, you're coming in a front desk, but where would you like to see yourself? Would you like to be the leader of all the front desks? You know, the multiple claims where you want to be somebody who's eventually moving up, and people who tend to have that kind of drive that want to like take themselves from one level and move up to, you know, the second level, the third level, the fourth level, those tend to be people who I think are going to be some of the best employees. And they're going to tend to be the ones that are going to be there with you long term. Those who are kind of, you know, so so lukewarm, I just want to do this, I'm happy with it, might be fine in the short term. But you do got to understand, at some point, there is a certain level of burnout. And the thing that helps keeps us going is moving on to the next level. Nobody wants to be a med student forever. I mean, you're just going to get burned out of it. Nobody wants to then you're like, oh, I'm so excited to be a resident, then you become a resident, you're like, this is awesome. And then you get I'm burnt out being a resident, then you get the fellowship, which is like one year, and then you're burnt out after six months of being a fellow. Yeah, I'm ready to be attending. And so this is if we feel the same way, they're going to feel the same way. So people will have that kind of ideology of like, I want to move up and having those opportunities for them. I think that's very big and starting to staff and the biggest thing with it that I also say, it got to you got to make a family like setting. Now you got to have your pecking order of obviously you're the boss and you got to make sure there's respect. But also you want to make sure that everybody has a voice. So I always when I'm with my team and bringing it together, I look at sports. I love sports. So I always use sports analogy. It's a football team. Obviously, we're the quarterback. We're the Tom Brady. We're actually we're the Pat Mahomes got a shout out my boy Pat Mahomes. We're the Pat Mahomes. But your front desk, that's going to be your center, right? That's the center giving you the snap. So that center is giving you all snaps. Well, guess what, you're not going anyway. So that front desk has to be on board. So everybody is going to be important. Everybody has a voice. And you want to make sure that their voice counts because then they feel part of a team. They feel good. They want to see, hey, you know what, I got that schedule. So hey, I took Hey, I made a few calls for you, Dr. Harris, you only had 10 procedures on your schedule. Now you got 15. I'm like, Okay, thank you. I see you. And just acknowledging them and like going back and they feel good because everybody wants to see the team win. If they don't feel like they're on the team, or you feel like you're here and they're down there, what are not going to work hard for you're not going to put in that effort. When you get an employee, they have three ways. They're either going to be below the expectations or below what that salary you're paying them, they're going to meet it or they're going to exceed it. Right. And everybody knows that I remember when I was at Ohio State, there was a janitor, he was the one janitor, he would clean the whole entire College of Medicine. And I was just like, I remember talking to him was like, yeah, this guy does the job of four people. And it's like, we pay him more. But we actually save money, because the money we would have paid for people, he does it for one and a half. So it's like, we always show him love. He says he needs something, we get it. He needs new cleaning materials, we get it. So just making sure that if you do that, you get those people who now exceed expectations. So now they're 1.5 x 2x, what you don't want the people you hire, and they're 0.5 x 0.25 x, because your business won't grow, because you're only as strong as your weakest link. And so when you have somebody who's not pulling, it's just going to drag you down. And then you got to get rid of them. And then the higher in the process of bringing somebody in that slows things down, right. So if I got my rad tech, and my rad, I had a bad rad tech, and I got a higher one, now I have procedures that are slowed down. Now it's me the one that's moving it. So that would be really difficult. So it's really just putting together a team building that continuity building that family setting, and getting people who want to be there that are going to work hard to want to exceed the expectations and have that motivation. So great. Yeah, so starting staff, I mean, you try to keep it lean and then you want to grow from there. I know someone mentioned about radiation technologists, you got to look at your state guidelines, what do you need for it, I'll tell you, when we first started, we had to get one, it was a carrying cost, we weren't doing tons of procedures left and right, nowhere near what we were doing what we're doing now. But it was something we had to spend for. And those in our area, it's hard to come by, right. So we got it, you got to make sure you understand your market. And you can put job postings out there and see what that kind of looks like, where you can partner up with colleges or institutions that kind of feed those types of graduates, medical assistant, you've got your clinical team, so that's your MA, or your LPN. And then you've got your admin. So it's either your front desk, business administrator, they may flex for the both. And then you want to start thinking about expansion, billing specialists, patient care coordinators, marketing associates, I mean, these are all things that you think you got to think about with growth. A good way to look at this too, is look at other people or other practices across the country, see what they're doing, and then see how you can adjust accordingly. Alright. So I kind of talked a few things on this, and you guys will have access to the slides, basically where to get your medical supplies, what places we use, what GPOs to consider, and then who to talk to. Your medical device reps definitely help a lot because they see a lot of practices in your area and see what other people are doing. So definitely reach out. But there are plenty of vendors out there. And like I said, I mentioned a lot of this. So the other thing just a little aside is ancillary and health tech is a huge new aspect or avenue for interventional pain and even just practices in general. I mean, we know about the classic DME, urine, drug screen and imaging. And I'll tell you between those three things, get your lawyer involved if you're ever interested, and you got to find out more information about it, because those are even more regulated than starting a clinic. Beyond that, all the health tech, you know, compliance is a big thing, precision healthcare management platforms. So doctor plans, salary, pain scripts, or health scripts. I mean, these are all like technology driven companies that really change your practice and also protect you a lot of the way. I know we're kind of breezing through this just because we're getting close to our end time. But you know, financials is a big thing. How did you raise money? Venture capital, private equity is so funny. We were at a meeting and one of the KOLs was talking about, oh, you guys won't be talking to private equity. And we were kind of laughing to ourselves because we actually had been sitting in a few private equity meetings before even, you know, getting started. So, again, it just goes back to if people aren't doing it, they have no idea what they're talking about. And a lot of times you will be discovered, you will be surprised at what type of opportunities are out there for you. Banking, hard money lending, you got to figure out what is your, you know, tolerance for risk. As an anesthesiologist, a lot of times we're trained to minimize risk, but you're going to figure out what you can handle and what you can't. And, you know, you got to, you got to risk it for the biscuit, right? So just things to think about along the way. You got to leverage your time and your personal savings. We were at a time where anesthesia paid really well. So we covered a lot of our downtime with going to anesthesia and covering anesthesia shifts. I'll tell you the one thing, great thing about that is we got to meet every surgeon in the city. So we developed relationships across the city with that. And that definitely helps a lot. Building business credit, line of credit, credit cards, these are things that you got to think about. It's like a completely different avenue from personal credit cards, right? And personal credit. And then I mentioned the state grant funding. So that's the other thing. Again, I think we're getting close to wrapping up or end of time here. What's on the horizon for us? An ASC development, you know, I was sitting at Becker's ASC, I go to that meeting a lot just to see what other specialties are doing this in this area. And we all talk about this. ASC is the way to go. If you're not growing, you're really not, you're not doing well. You have to focus on growth, growth, growth, at least until we kind of figure out what healthcare kind of normalizes into. So understanding side of service differentials, expansion of services, partnering with other, you know, physicians, what is credentialing, insurance negotiation, contracting look like prior authorizations and post procedure clawbacks and compliance. I mean, starting an ASC, a surgery center is like starting a brand new practice. And that's how you have to approach it. And that's when when I talk about that, it's just spending the time and planning it out. Because if you're not doing that, you're really going to get yourself into some trouble there. Dr. Junaid, do you have anything else you want to add? I think you covered I think you covered a lot of it. You know, I think that we were just lucky that in the time that we decided to do this, you know, like types like Dr. Ghammi said, you know, anesthesia was just blowing up. I mean, since COVID, the market's been so, you know, dependent on anesthesia providers, and we were just lucky to have opportunity to be able to get capital to hire the right employees. And to start the practice. I mean, you know, that was kind of a, you know, just the timing thing for us. But other than that, I think, you know, you got to do your homework, got to do your research. And you know, there's obviously some risk involved, you know, and so managing risk and being able to tolerate risk, it's going to be a big part of this, you know, opening up a practice. Any final remarks, Dr. Harris? Yeah, I agree. I mean, remember, we're all doing pain management. None of us, it's not a straight residency to become a doctor. It's not a straight residency to become a pain management, you have another skill, your PMNR, your site, your IM, your anesthesia. So using those opportunities for people coming out of fellowship, those will be opportunities to use those skills to kind of build capital and give yourself an opportunity to have those savings to go into private practice. If you're already working in private practice, and you're making money, then putting money to the side, using that money, making that money, making investments and using those investments, and those investments that you use to start your own practice. So just know that you got to make sure you have the planning, right, you're going to have to know what it's going to take, what are you going to need to do? And what is going to be the steps to be able to do that. And so if you like you said, like Dr. Takamatsu Madami said, if you don't have the vision, and you don't have the steps, it's just not going to work, can't jump into this and do this could be like jumping in the middle of the Pacific Ocean, and trying to see if you can get to land, you know, you might get lucky and you're like, you know, 200 feet offshore, you might be in the middle of it. And so, you know, that situation is not ideal. So again, make sure you do your homework, make sure you do your research, make sure you add plenty of questions to people who know more than you do. And if you do that, I think you have a lot of success. So great. And you know, you guys can more than welcome to reach out to us. Find us on our website, pzohio.com. I'll tell you, we spent time visiting multiple practices across the country. And they went out, you know, help and aid and suggestions and, you know, their, you know, expertise into helping, you know, mold our practice, and we'd be happy to help. Because at the end of the day, like if we're able to support other physicians accomplish what they want, it's only going to elevate our field, our care and patients are going to help or get the help that they need. And they won't be waiting, you know, long periods of time for that. So and with that, I think we're all done. Any leftover questions, please send it over. And then, you know, thank you all so much for your time. Thanks a lot, everyone. Thank you, everybody.

private practice

interventional pain

neuromodulation

practice models

healthcare regulations

opioid epidemic

community engagement

staff selection

marketing strategies

practice stability