04-04 Working Like A Small-Town Doctor

[00:00:03] Speaker A: Hi, everyone, and welcome to the Nervous Herbalist, a podcast for Chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it. Hello, everybody. Welcome back to the Nervous Herbalist. My name is Travis Kern, and I'm. [00:00:22] Speaker B: Here with Travis Cunningham. [00:00:24] Speaker A: And on today's show, we want to talk to all of you about this idea that we've been kind of rolling around trying to capture, a component, a quality of practice that we have decided to call working like a small town doctor. Now, TC And I, we live and work in Portland, Oregon. It's not a small town. [00:00:48] Speaker B: No, it's not. [00:00:48] Speaker A: I mean, it's not, you know, a huge city like Seattle or New York or something, but, you know, there's like 800,000 people here. It's a pretty big space. And our clinic is sort of tucked in a little neighborhood area of Portland. Portland's a very neighborhood heavy city, and so a lot of our patient base comes from the area kind of immediately around our clinic. But nonetheless, like, even this tiny neighborhood of Portland has tens of thousands of people in it. Yep. So it's not exactly a small town. But we've landed on this idea because there are some aspects to building a practice that we think are valuable when you're channeling this idea of being a small town doctor, someone who is connected to the community that they treat and who sort of steps into an important position of responsibility for their patients and for their outcomes. And so we kind of wanted to tease that apart a little bit and talk about it, because we think that it's an important quality not only for building a successful business, which we'll talk about, but we also think to help keep practitioners connected to the people that they serve in a way that improves patient outcomes, but also keeps us from burning out. [00:02:07] Speaker C: Yeah. [00:02:07] Speaker A: Keeps us from forgetting why we do what we do. And it has a sort of reinvigorating component that if we are working with cases in a really close way, that it just seems to us that people can stay inspired. [00:02:24] Speaker C: Yeah. [00:02:25] Speaker A: In a way that's hard to do sometimes if you're just sort of a face or faceless crowd kind of vibe. [00:02:31] Speaker B: Yeah, we were. We were. Travis and I were sitting sometime last week, and we were going over the. The translation of one of the Fukushin texts by Inaba, which is. [00:02:43] Speaker A: That's because we're nerds. [00:02:44] Speaker C: Yeah. [00:02:45] Speaker A: But. Yeah, we were doing that. So, anyway, carry on. [00:02:48] Speaker B: But we were talking about how it's just clear if you Read the writings. This guy who's wandering around the countryside in the 1700s or the 1800s of Japan and their primary care docs, like, they are just in it. They're seeing all kinds of stuff. There's an abundance of formulas in, in the text that are additional family formulas that are for specific types of purgation. [00:03:14] Speaker D: Right. [00:03:14] Speaker B: That's like a thing that's featured in the text. And it just goes to show that in the commentary how serious the stuff that they were treating was. Like they were the. The doctor that was going to treat those things. And we were having a discussion about the intrinsic advantages and disadvantages to that situation where, like, we live in a space now where, at least in Oregon, we're not primary care physicians. We don't have that distinction. And because we don't have that distinction, there's a lack of pressure to figure the medicine out, to become good at it in a certain way that you're forced into if you're the person that people are going to see for real problems. [00:04:02] Speaker D: Right. [00:04:03] Speaker B: And we sort of find ourselves in a bit of a nuanced position in our current practice because we are. We market ourselves as internal medicine specialists. [00:04:15] Speaker D: Right. [00:04:15] Speaker B: But we're not technically primary care physicians. But a lot of people have come in to see us in ways where, let's see, the lines of those things are a little closer together and you have to make decisions if you're in that position where, okay, we need to refer this person out in this case or in this other case, we don't. We can handle this, but it's not always so clear in the clinic. It's sometimes it's a little bit stressful, especially when you're getting started. And. But if you can walk that line. Well, I do think it has the positive side of forcing you or incentivizing you to become more skillful and more tactful as a clinician. [00:05:02] Speaker A: Yeah. I think I want to add to this question of, of the pressure piece. The thing is, is that in. In the west, and really in many ways in China too, but it's a little bit more complicated there. But certainly in the west, most states in the United States don't allow Chinese medicine clinicians to be primary care. Right now, some do. I think it's New Mexico, California, Florida. [00:05:30] Speaker B: Yeah, something like that. [00:05:32] Speaker A: There's a handful. And in each of those states, there are, you know, I think maybe too, we should take a step back as to why. Right. Like there's a dominant opinion, I would say even a dominant opinion among Chinese Medicine providers that we are not able to be primary care. Like, we lack the requisite skills and it would be irresponsible to take on the position of primary care. And I suppose the question arises. It's a complicated question because I can see where people are coming from, from that point of view. Sure. [00:06:07] Speaker C: Yeah. [00:06:07] Speaker A: Because we live in a certain system that has certain expectations around what counts, you know, for primary care. And without doubt, we didn't get training in school on suturing, for example, or advanced wound care or basic sort of surgical procedures, you know, draining abscess or things like that. Things that can be done in the primary care office of a naturopath or a biomed or an osteopath. [00:06:36] Speaker D: Right. [00:06:36] Speaker A: People who can be primary care in Oregon. And so from that point of view, from a sort of base skill set level, I think the criticism is valid, though, to be honest. I'm sure we could all learn how to suture. [00:06:53] Speaker C: Yeah. [00:06:55] Speaker A: With some training. [00:06:56] Speaker C: Yeah. [00:06:56] Speaker B: If it was trained, like. [00:06:59] Speaker A: Yeah, like if it were possible, you could just go to a couple of weekend seminars and learn how to suture. Sure. [00:07:05] Speaker B: And if the. If the education was set up to design us to be primary care. [00:07:10] Speaker A: Yeah. We would have learned that. [00:07:11] Speaker B: We would have learned that. And there would be other things emphasized. Like more emphasis on identifying red flags. For example, like where the person needs acute. Acute emergency medical care. [00:07:24] Speaker D: Right. [00:07:25] Speaker A: Yeah. The place where you would send them to the emergency department because, you know, something's unfolding in a way that's going to require surgery or, you know, dramatic intervention or what have you. Which would be the same for biomed primary care. [00:07:38] Speaker B: Absolutely. [00:07:38] Speaker A: So, like, if someone walks into the primary care clinic for the biomeds and they're having a situation that is clearly going to need more advanced treatment, they're referring them to the ED as well go to the emergency department right now. So I take the criticism from a core skill level, but I think that the criticism is actually more insidious than that. I don't think it's actually just like they didn't learn how to suture. [00:08:05] Speaker D: Right. [00:08:05] Speaker A: I think that the deeper criticism, and actually one that is maintained even by some people in our profession, is that our medicine is not up to the task of dealing with all of the things that people walk into primary care with. [00:08:20] Speaker D: Right. [00:08:21] Speaker A: And that notion I deeply disagree with. [00:08:25] Speaker B: Me too. [00:08:25] Speaker A: And I think it's a representation of a couple of things. I think it's the fact that a lot of people do our work and they don't use herbs, and so they're thinking like, well, how am I supposed. [00:08:35] Speaker B: To deal with a uti? [00:08:37] Speaker A: A UTI with acupuncture. [00:08:39] Speaker B: With acupuncture. [00:08:40] Speaker A: And it's like, yeah, you're right, you're probably up the creek with that. At least you could probably help. Not in the speed with which you need to help. And so you feel like you couldn't do it. And so you get into this kind of practical thing, right? Where like in a state like Oregon, whether you use herbs or don't use herbs, everyone has the same license. So how could you, how could, like, even if people in Oregon were like, we want to help Chinese medicine people become primary care, how would you do it? Well, you would need different licensing. [00:09:08] Speaker B: You would, right. [00:09:09] Speaker A: You'd have to have distinctions made between who's qualified and who's not qualified. And that's super messy and blah, blah, blah. I get it. Whatever. On a philosophical level, though, the truth is, is that Chinese medicine writ large, acupuncture, herbs, cupping, moxa, the whole game, the whole package of Chinese medicine is absolutely capable of serving as primary care, because that's what it was. [00:09:31] Speaker B: Oh, and I would say, in my opinion too, it's better in many regards. So we have answers for problems that the typical, the status quo medicine that stands in for primary care doesn't have any answers for. [00:09:48] Speaker A: That's true. [00:09:48] Speaker C: Yeah. [00:09:49] Speaker A: And not only do we have answers for things, particularly like functional problems, you know, people have this strange downbearing sensation when they pee, but they don't have an infection. There's no blood cells in their urine. Well, just take some more antibiotics. I guess we just need to get rid of it. You know, it's just, it's not precise pt. [00:10:09] Speaker B: Go get your pelvic floor strengthened. You know, like that's really all that you got. [00:10:13] Speaker A: It's just not very precise. And I think that, that not only do we have answers for things in the medicine that other people don't, we also the design of our practices gives us more time. [00:10:25] Speaker D: Right. [00:10:26] Speaker A: And this is important, for example, with patients who have diabetes. So when you get diagnosed as diabetic in the biomed context, and some of the hospital systems are getting better at this, but your doctor, you know, you run your annual labs, one year it comes back pre diabetic. And so then they're going to order labs twice this year instead of just once. And your A1C is creeping up. And so now A1C is at 7:2 and you're officially diabetic. So you get set up, your doctor schedules, one meeting with the diabetic nutritionist. So this is a dietitian. Certified licensed dietitian. My mom was one for 40 years, so I know about this quite a lot. And the patient gets set up with a meeting. And in that meeting, that dietitian has an hour to basically explain how to better live your life with diabetes through food, managing it through food. That appointment in a good hospital system with many available trained people will happen two to three weeks after your initial diagnosis. In many cases it could be six to eight weeks after. And it will be one time. Yeah, one time. Just once. [00:11:38] Speaker C: Yeah. [00:11:39] Speaker A: Now, again, high risk populations, certain hospital systems, age demographics, There are variables here where some people might get set up with two or three meetings with a dietitian that'll take place over four or five months. [00:11:52] Speaker D: Right. [00:11:52] Speaker A: But the truth is, is that most people just get a passing thing or they get told like, hey, you need to schedule with the dietitian and then they never do. [00:12:00] Speaker D: Right. [00:12:00] Speaker A: And no one follows up with that because what we're going to talk about today, basically like that there's a lack of personalization, there's a lack of individual tracking and care. [00:12:09] Speaker C: Yeah. [00:12:10] Speaker A: And the truth is, is that when someone has a high A1C, their diabetes is coming in high, the blood sugar, excuse me, is coming in high. There are ways to fix that with food. Oh yeah, like you don't like the idea? That's like, oh, we just need to immediately get on medication and that'll handle it. It's like, no, no, no. There are things, fiber, fruit, carb management, protein management. Like there's methodologies, frankly, that are well established and have really, really great clinical outcomes where people can fundamentally change their A1C levels with food. But if the person is sitting in front of you with high blood glucose, their lifestyle is not going to be able to be changed with a 60 minute meeting. [00:12:52] Speaker D: Right. [00:12:53] Speaker A: Like, there's just no accountability there. You need more consistency, you need more time to explain. They need one to digest, they need to come and explain stuff to you. So my point is just that not only do we have solutions, herbal solutions, acupuncture solutions, we have lifestyle solutions. And our business structures are such that we, many of us, have time to talk to people about it. [00:13:14] Speaker C: Yeah. [00:13:15] Speaker A: And that makes a big difference. [00:13:16] Speaker B: It does. [00:13:17] Speaker A: Because now, you know, think about all of the businesses that have cropped up in the last 20, 25 years that are healthcare adjacent. [00:13:26] Speaker B: I'm thinking like zoom care type stuff. [00:13:28] Speaker A: No, no, I'm thinking like life coaches, wellness coaches. So these are not official therapists. And they're not actual medical people, but they're advocates. They're people who are saying like, yes, you can, let me help you join my program. We meet every Friday, support group, community systems. Right. And these have grown up as sort of. I mean, in the most generous sense, they're allied health folks. [00:13:55] Speaker D: Right. [00:13:55] Speaker A: They're sort of in the vein of helping people get better outcomes. In a less generous sense, they're maybe slightly exploitative of holes in the market. Right. And I think we can probably find examples that run the whole gamut. But that stuff emerges because we don't have the personalized care inside of the mainstream system. Otherwise there'd be no need. The market has created an industry because there was a gap. Yes. And for better or for worse, I would say many a times for worse. Medicine is part of our capitalistic system and it went well. There's a need here. People need someone to work on their behalf, to fill in the human community piece that's been lost from the mainstream medical structure. [00:14:44] Speaker D: Right. [00:14:45] Speaker A: And this is where we are like, we are sort of a built in medicine and life coach kind of deal, you know, because we're not only talking about what you need to do for your body, but we're also like for your take this medicine. Right. But we're also saying this is how you can act, behave, live in a way that would be more conducive to your health in the long run. [00:15:05] Speaker D: Yeah. [00:15:06] Speaker B: And before we get into the specifics, I think it's important to say that neither of us are suggesting that everyone has to use this sort of model or framework of the small town doctor. Like you can just be an acupuncturist working at a high volume clinic, treating people's shoulder pain. That's totally cool. [00:15:26] Speaker A: And you're doing good work. [00:15:27] Speaker B: Yeah, you're doing good work. [00:15:28] Speaker A: You're doing good work. This show is herbal heavy, Right. I mean, it's the whole point of the reason we keep it. And so the. I think in many ways we're talking to people who deal in herbs. And I also. We know a lot of acupuncturists too, who are only acupuncturists and yet also serve in a similar way where they're touchstones for their patients. They create really deep bonds. There's really strong rapport. It's not like it can only be done by herbalists. And it's not like functioning primarily as an acupuncturist is somehow less or diminished. But I do think that if you're in the position as a practitioner and you. There's a couple of things I think, that might stand out in your experience that say, maybe you want to explore this more. One is you just feel a draw to it. The idea that you'd like to be a touchstone for people in your community. Right. Like, if they have a problem, they call you first. If that's the thing that would be intriguing to you, then you're in this space. [00:16:28] Speaker C: Yeah. [00:16:29] Speaker A: Also, if you find that you have patients come in for one visit or two visits and then they're gone and you're like, why aren't they sticking with this? What's going on? Then maybe there's a connection, a community piece that needs to be expanded. Something we'll talk about later in the episode too, is maybe too. How is the business side of your stuff organized? How are people paying you? What's the funnel of their traffic from a financial point of view that's encouraging them to come back or not. [00:16:57] Speaker D: Yeah. [00:16:58] Speaker A: And so these are the things to consider. So, yeah, this isn't. Not everyone needs to be a small town doctor. There's lots of ways to do our work and lots of ways to participate in ways that are satisfying to you and helpful for your patients. But if you're in this heavy herbal space, if you align with or resonate with any of the things we've mentioned so far, then maybe this is something that you want to think about. Yeah. [00:17:22] Speaker B: And it is a way to scale your practice, to build your practice, which is what we're going to do, I think, elucidate here through some stories. [00:17:29] Speaker A: Yeah. So maybe let's start with that. So when we were trying to design how to talk about this, like many of the things that we do, we want to anchor it in a real life example, in something that we think is a tangible explanation of what we're talking about. And that really is the beginning of a story that happened before COVID when we first opened the clinic, which seems like a million years ago now because of the COVID time warp. I mean, it wasn't that long ago, but it does feel like it sometimes. And that was when we basically got a random phone call. Why don't you tell the story? [00:18:03] Speaker B: Yeah, so we got a random phone call, which I think actually Travis K. Probably answered. I don't think I answered the. [00:18:10] Speaker A: Yeah, I did the phone because I just happened to be the person answering the phone that day. [00:18:15] Speaker B: And it was a woman on the other end and asking if we had any treatment for kidney stones. And she believed she had kidney stones because she was getting back pain that was close to the area of the kidney. [00:18:29] Speaker D: Right. [00:18:30] Speaker B: And she wasn't sure what to do about it. She wanted to see if there was something we could do to help her. [00:18:35] Speaker A: And she was looking for, quote, natural. [00:18:39] Speaker B: Natural solution. [00:18:40] Speaker A: Yeah. Which is a lot of the kind of calls that we'll get. You know, people are like, obviously they know they could go to the doctor, to the. To the biomedical, but they were looking for a natural solution. [00:18:49] Speaker C: Yeah. [00:18:50] Speaker A: So, yeah. [00:18:51] Speaker B: So they came in for an appointment. I ended up seeing. Seeing the patient, writing a formula. And the formula was very helpful. And to be honest with you, I don't even remember which formula it was because this was literally like in our first or second year of practice. So it was quite a while ago, but it was very helpful. The pain that she was experiencing almost immediately started getting better. And I'm actually not sure if she passed a kidney stone or not, but the pain, which was the chief complaint, got better. [00:19:24] Speaker A: Right. [00:19:25] Speaker B: So within a week, they called us back. I want. I wanted to check in with them to make sure that they're doing better. [00:19:31] Speaker D: Right. [00:19:32] Speaker B: They called back and they said, well, one of the members of our. Our family unit is really struggling with some health things. We'd like to bring him in to see you. [00:19:42] Speaker D: Right. [00:19:42] Speaker B: So this is, again, like, this is the first link. So you do some internal medicine work, you get a good result, and then you get a referral. [00:19:51] Speaker D: Right. [00:19:51] Speaker B: This is kind of how a lot of this stuff works. So then they brought their family member in, who we're going to call Mac was not his real name, but for the sake of discussion, it's easier to give a name. So Mac came in, and Mac is a type 2 diabetic with unmanaged diabetes for the last eight or nine years, and he's in a wheelchair, which is devastating for him because he's a musician. In fact, this group of people were musicians in a group that would perform at different clubs around town, mostly for older people, like Elks Clubs and things like that. [00:20:35] Speaker A: Yeah. [00:20:36] Speaker B: And Mac was a singer, keyboard player, and he would do pedals, use the pedals. And after the severity of his neuropathy, he could no longer play the pedals and couldn't walk for very long without having extreme pain and discomfort with a neuropathy. So Max started coming in, and just for herbs, we didn't do any acupuncture at first, again, because I think the touch point was I had written a formula for the first person. [00:21:15] Speaker D: Right. [00:21:15] Speaker B: And that was very helpful. So they're like, oh, the herbs. Let's do herbs. [00:21:18] Speaker A: We're gonna do more of that. [00:21:20] Speaker B: So I ended up treating this patient for, I think, two or three weeks. I wrote a formula, and I do remember this formula. So the first formula I wrote, this gentleman was Shui Fuji Tong modification. Just. I. I was like. I was a young. A youngin in the field. And I was like, well, the one thing I can be sure about is that there's blood stasis. [00:21:44] Speaker A: Exactly. Yeah. [00:21:45] Speaker B: We need to move the straight forward. [00:21:47] Speaker C: Yeah. [00:21:47] Speaker A: Move the blood. [00:21:48] Speaker B: So I use Shui Fujiutang, probably with some modification I like to. We learned at the time to add bugs into the formula if there was low collateral damage. So I probably did that. And the result in those first two to three weeks was miraculous. Like, it was just nothing short of miraculous. He was able to get up out of the wheelchair. The neuropathy improved by a huge percentage right away. And a lot of the other symptoms he was experiencing got better. He was able to go back to using the. The pedals in the performances and walk around the next time he came in. He didn't have a wheelchair, so he was just super, super thrilled. And that was only the beginning of this case. This is the other thing you realize after you're in the field for a while is you can take a snapshot of a case after something resolves, but it's not the end of the story. Cause there's always going to be something else that happens, and then. And then you have to go through that. And anyway, because I had gotten such good results in the early part of the treatment with this patient and his family, Mac ended up just telling everyone about us. And because they were performers for this group of mostly older people, a lot of whom had neuropathy. [00:23:21] Speaker A: Neuropathy. Yeah. I mean, consider the audience said, Right. They're performing in places traditionally filled with older folks, ELKS halls, VFW halls, stuff like that. And TC had just. From Mac's point of view, TC had just cured his neuropathy. [00:23:37] Speaker D: Right. [00:23:38] Speaker A: And Mac was a punny guy, so he would love to be like, are you looking for the proof in the pudding? I'm the pudding was his phrase. And he would get all these people and just be taking stacks of TC's business cards and just handing them out at shows, being like, you need to. Need to go see this guy. [00:23:56] Speaker C: Yep. [00:23:58] Speaker B: And I will say that the. The other side of this. So this. This all sounds great, but what the reality of. Of working with Mac over the years that. That we Did. Came with a lot of ups and downs. There were really positive things that happened. But then there were also times when his health would tank. There was one time when he. He had some kind of infection that went septic, and he. He barely survived. Had to go into the hospital and get all kinds of antibiotics and stuff. And eventually he did pull out of it, and then we were able to help him to recover with our. [00:24:37] Speaker D: With our work. [00:24:39] Speaker B: But this was also a situation where the family would call us for anything that would happen. [00:24:46] Speaker D: Right. [00:24:46] Speaker B: So somebody gets a cold or during COVID times. [00:24:50] Speaker D: Right. [00:24:51] Speaker B: Oh, I think, like, you know, somebody might have Covid before there were tests, you know. [00:24:56] Speaker A: Right. [00:24:56] Speaker B: What can we do? Can you write us something? And so not just me, but also Travis K. Over here, we kind of became workers of these cases, like, all, like, as. As often as they needed care. And we can talk about what that looked like, too, because these people were cash patients the whole. The whole time we worked with them. [00:25:21] Speaker A: And it was. It was also stuff. I mean, it was colds, like TC Said. I mean, it was dermatological stuff. [00:25:27] Speaker C: Yeah. [00:25:27] Speaker B: Skin stuff. [00:25:28] Speaker A: It was sleep problems. I mean, it's. It's really just the. The full gamut of stuff that's bugging a human. [00:25:35] Speaker C: Yeah. [00:25:35] Speaker B: Pain. All kinds of things. [00:25:37] Speaker A: All kinds of pain. Yep. We became. We became the first call. [00:25:41] Speaker D: Mm. [00:25:41] Speaker A: And that happened because there was such remarkable success in. In the early days. [00:25:47] Speaker C: Yep. [00:25:47] Speaker A: For sure. I mean, I think it's. It's probably inarguable that if you hadn't knocked it out of the park in those first ones, we may not be telling this story. [00:25:55] Speaker D: Right. [00:25:56] Speaker B: Sure. [00:25:56] Speaker A: But you did. And that. But it wasn't just herbal success. [00:26:01] Speaker B: No. [00:26:02] Speaker A: That kept them as part of our. As part of our family, our clinic family. It was the bond that gets built by checking in, by being agile with formulas, by saying, like, hey, you've got a cold. I'm gonna write you this thing. I want you to take it for three days, and I want you to call me and let me know how's it going? How's it looking? What's moving? There was an attention to detail on our part that I think encouraged the ideas intentionally that we were here for them. [00:26:37] Speaker C: Yeah. [00:26:37] Speaker A: You know, that we were here to provide the kind of care that we knew that we could provide, because we also learned over time that they were not, at various points, they weren't insured at all or they weren't very well insured medically. And they. All of them really, in this group, this family group, were distrustful yeah. Of the mainstream media medical system, which is not uncommon. I'm sure many of you listening come across patients who are distrustful of the mainstream system. Maybe yourself distrustful of the mainstream system. But the truth was, is that these folks were probably not going to go. [00:27:14] Speaker D: Right. [00:27:15] Speaker A: In fact, in many cases, maybe not in many, but certainly in several, you had to say, look, I did. You need to go. [00:27:22] Speaker B: You need to go to this person. [00:27:24] Speaker A: To go and deal with this. Because this is. [00:27:26] Speaker C: Yeah. [00:27:27] Speaker A: This level of presentation is beyond what I can do fast enough so these guys can do it faster. They have access to other things. You need to go now. [00:27:34] Speaker C: Yeah. [00:27:35] Speaker A: And without that, I don't know that they would have. [00:27:37] Speaker D: Right. [00:27:37] Speaker C: Yeah. [00:27:38] Speaker B: No, we definitely had to refer them to specialists at different times for different things. But the benefit of that was this person wasn't managing their diabetes really with anything at all, and it was causing all kinds of damage. And through, I think, the trust that we established in the relationships, we got them to work on their. Their diabetes actively like that. Lots of dietary stuff. We taught them how to manage the blood sugars. At one point, we referred. I referred Mac out to a very experienced naturopath that I trust to do some specific work with some of those things. And that was very helpful. [00:28:23] Speaker A: We ended up getting them set up with a continuous glucose monitor. [00:28:27] Speaker C: Yeah. [00:28:28] Speaker A: Which with help from diabetic dietitians that I know through my mom's connections, we were able to, like, train them up on that, do my own kind of training on it. So I really knew how the system was working. [00:28:40] Speaker C: Yeah. [00:28:40] Speaker A: And be able to help them understand how to use it, how to read it. Because again, the one meeting with a dietitian, one meeting with a. A biomed doctor to get the cgm, and then that was it. [00:28:52] Speaker C: Yeah. [00:28:53] Speaker A: It was like, okay, good luck. [00:28:54] Speaker C: Yep. [00:28:55] Speaker A: Manage your sugars. You know, like, it just wasn't. It wasn't enough. [00:28:58] Speaker D: Right. [00:28:58] Speaker A: Uh, but we were in that position to do it. And it's an interesting. You know, I guess we should. We should tell the end of that story, too, because it's an important one, I think, to highlight the value of the relationship initially, but also over time. [00:29:13] Speaker C: Yeah. [00:29:14] Speaker A: So ultimately, Mac TC had been treating him. I mean, gosh, it was five or six years. Six years. I think, in the end. Yeah. You know, they were in. Mac was in consistently, you know, once or twice a month. And then other members of his family were in for various, you know, needs and conditions. And then ultimately he ended up with a really, really bad case of kidney stones. [00:29:40] Speaker B: Kidney Stones, which is. I didn't even realize until we were organizing the topic of this. This. This podcast that. That his family members. Kidney stones were the things that brought them in. And the kidney stones at this point were. They were very large, like two. Probably too large to try to work on with herbs, and also very painful. So we referred him out to. To get it. To get an ultrasound. And. And it was. They. They decided they had to operate. [00:30:14] Speaker A: Yeah. Because they were actually. They were too big to try and break up, like, with. With sound waves. So they were like, we have to go in and remove them. Yeah, so they did. [00:30:23] Speaker B: Yeah, so they did. And they successfully removed the kidney stones. But after the surgery was completed, during the recovery phase, some of the food that Mac ate was getting stuck in the esophagus and wasn't getting down into the stomach, and he was very uncomfortable. And so they did some kind of a test. Maybe it was a scope or something like that, but they determined that there was an obstruction and that they needed to go back in to do surgery. And unfortunately, when he went under for that second surgery, he aspirated during the surgery and passed away. [00:31:06] Speaker A: Yeah. Yeah. And it was such a. Such an abrupt tragedy because everything had gone so well from the previous surgery. [00:31:13] Speaker B: Yeah. And the. The weird thing about it was, since I had started seeing Mac, his health had been the best I'd ever seen, aside of the kidney stones. His daily health was so good. It was so strong. They were regularly performing, you know, five nights a week. [00:31:33] Speaker A: Yeah. [00:31:33] Speaker B: Like, just incredible. Like, most. [00:31:35] Speaker A: Most of the year, they were bicycling. [00:31:37] Speaker B: Bicycling. [00:31:38] Speaker A: They were doing outings. [00:31:40] Speaker B: And this is a. This is a guy. And his. I should have said this is a guy in his late 60s. [00:31:45] Speaker D: Right. [00:31:46] Speaker B: And. And then, yeah, kind of out of the blue, and not even for the kidney stone portion of the intervention, but for this sort of extra thing. [00:31:56] Speaker D: He. [00:31:57] Speaker B: He died. [00:31:58] Speaker A: Yeah. Surgical complication from aspirating while. While under. Yeah, it was. It was a huge tragedy. Massive community outpouring. Oh, man. You know, Mac. Mac had Mac and. And the whole family because, you know, they. They worked together as a band. I mean, they had just connected with so many people, and they were. Maka was such a genuine human being, just absolutely concerned about the good in people and positive support. And he exuded that constantly, and as does the rest of his family. And so it was a super. It was so sad. Such a sad loss. It felt very tragic and too soon, all things considered. And then, you know, afterward, Mac was the primary driver for why folks like he or some member of his family were here consistently because he'd be here every two weeks. And. And so I wanted to make sure that we continued to be able to support the rest of the family, even if there wasn't that kind of driving. [00:32:56] Speaker C: Yeah. [00:32:56] Speaker A: You know, weekly force. And so we, you know, called them and spoke to everyone and was like, look, you know, we will continue to, like, we want to continue to support you guys with whatever comes up. So, you know, you give us a call if there's a problem. Don't worry about, you know, because it was unclear kind of in the beginning what their livelihood was going to be like, because now that there's a problem with the band's composition, are they going to actually have gigs? Can they. Money? You know, this is a classic people artists working, you know, paycheck to paycheck. It's. It's tricky, you know, to live that life. And so we were in a position to say, look, don't, you know, don't worry about the cost of the. The visits. Right. Like, you guys buy the herbs, but the rest of it, you know, we'll deal, we'll figure it out. You know, we'll work something out. And, you know, that was a bit of our gift to them for having been, you know, in our clinic family for so long, but also just, you know, it's something that we could do. [00:33:50] Speaker C: Yep. [00:33:50] Speaker A: At the time that it's nice to be able to do something for people, you know, to feel like you can support them in that way. And they've taken us up on that. They've continued to have. [00:33:59] Speaker C: Yeah. [00:34:00] Speaker A: Be participants here. And it's the same. In fact, in many ways, it. You know, Max gone. But the way that the rest of his family interacts with the clinic here is. Is almost identical to how it was before. [00:34:10] Speaker C: Yeah. [00:34:11] Speaker A: Something comes up. We get a. We get a call about it, we get an email. Someone comes in for a visit, write a formula, and they're working again. They're doing gigs again. They reorganized the band in such a way that they can continue to. To do a lot of the work that they did when Mac was alive. And, you know, it's still. It's going well, all things considered. You know, obviously, everyone misses him, and it's a. It's a big difference, but, you know, they're. They're able to persist. [00:34:38] Speaker C: Yeah. [00:34:38] Speaker A: As it were. And it's interesting to be in the. The doctor's position in all of this. Right. Because we are not members of their family. We knew Mac well We spent. You in particular, spent a lot of time with them. [00:34:52] Speaker B: Yeah, I did. [00:34:54] Speaker A: But, you know, Mac was also a. He was a. He was a DIYer. Like I am of some skill, actually. So he and I actually talked quite a lot about building things and making changes. And he told this story that I really liked. I was telling him about this project that I had done at my house and. And he just looked at me and he was like, that was a lot of work, huh? And I was like, yeah, it was. And it was interesting because I do a lot of pretty big building projects myself. And people will see them and they'll be like, wow, that's crazy. I can't believe you did that. But when someone who also does work like that says, hey, I see how much work that was. [00:35:33] Speaker D: Right. [00:35:34] Speaker A: It has a profound impact because I know that you know exactly how much work this is. Whereas, like, most people. See, like, people basically be like, you put a porch on your house and you built a bookcase. Wow, that seems wild. And it's like, those things are not at all the same, you know, but someone like Mac understood that. And so anyway, he and I would talk about that. And so we. There were things that we interacted with and engaged with beyond just the treatment room. And we had been to a couple of their shows and, you know, TC and I are very mindful of not blurring lines between. Between patient life, clinic life and real life. Regular life, perhaps not real life, but we're very mindful of that for a lot of reasons. I think it's dispositional. And also, we just. We don't want there to be confusion about, like, what everyone's roles are in this place. And so it can be a little bit tricky, delicate. I'm not sure what the word is when. When your rapport with a patient is really, really good. And a natural extension to that would be like, hey, we should grab dinner sometime or let's. Let's hang out in the park. Or, you know, it's not. Not in a. An inappropriate way, but just in a natural, like, hey, we seem to be getting along really well. I like you, you like me. Let's go with our families. Let's do a thing, you know, and we're usually pretty, like, non participative in that. [00:36:56] Speaker C: Yeah. [00:36:56] Speaker A: You know, just by default, it's like, oh, yeah, just let me know. And it just never really comes together. Right. Because everyone realizes that. But in this case, even though we maintained those boundaries, I think pretty well, we were still able to build a closeness and a Rapport and a bond. That is sort of the inspiration for this idea of small town doctor. [00:37:17] Speaker D: Right. [00:37:18] Speaker A: It felt that way. It felt like you would see Mac and his family, you know, in the restaurant getting breakfast. Like we never did. It was a huge town, but like, but that's how it would seem. Like we'd catch them on Main street, you know, that kind of thing, and say, hey. And everyone would know it and you know, hey, how's, how's that leg doing? You know, that sort of energy, which isn't really how most of us get to operate, but we, we did with them. And I think it was not only really satisfying from a patient clinician interaction point of view, like a professional satisfaction. Of course, it, I think, made better outcomes for them because they came to us first. Makes it easier to treat if you wait months and months and months for a problem to get worse. And then thirdly, it was actually really great for business. [00:38:05] Speaker C: Yeah. [00:38:07] Speaker A: And I think of that, you know, it for me, in all kinds of aspects of my life, if I can figure out ways to align everyone's interests. [00:38:16] Speaker C: Yep. [00:38:16] Speaker A: Then that's really great. You know, my personal interest, my business interest, and the patient's interest. If all of those things can be aligned, working in parallel, that is perfect. [00:38:27] Speaker C: Yeah. [00:38:27] Speaker A: In my mind. And this example was one of the ways in which we were able to do that. [00:38:32] Speaker C: Yeah. [00:38:58] Speaker A: I think maybe we should talk a little bit about. About how that was possible relative to the fact that they were out of pocket patients versus if they had been insurance or sort of what the dynamics are there. [00:39:09] Speaker B: Sure. Well, I think it would be harder to do it if they were insurance patients, first of all, because the thing that, that, you know, we've discussed many times, and I don't know how much we've talked about it on the podcast, actually, but the thing that tends to happen in a place like Oregon, where most people who have insurance benefits have acupuncture benefits. [00:39:33] Speaker A: Right. [00:39:34] Speaker B: You understand, is not the case with many other states, is that you get a certain amount of visits approved and then there's this tendency to want to hold on to visits per year. And once the visit limit is met, then there's a tendency not to come back in. [00:39:52] Speaker D: Right. [00:39:52] Speaker A: Out of visits. Can't do it anymore. [00:39:54] Speaker B: Exactly. Whereas if somebody is a cash patient, they're used to paying cash. They understand the dynamic. [00:40:01] Speaker D: Right. [00:40:02] Speaker B: So if something is a problem, there's going to be maybe a hesitancy to come in a little bit in general, but not specifically at any one point, if that makes sense. So like this, the cost of the visit is the same. The cost of the herbs generally in the ballpark. Like, everyone knows what it's going to be cost wise. And the issue is like, okay, how do we get these people better as quickly as possible? [00:40:29] Speaker D: Right. [00:40:29] Speaker B: Is kind of the idea. [00:40:31] Speaker A: Yeah. I mean, I literally just had this exact situation happen on the insurance side with a completely different patient. But I've been treating this patient for this kind of repetitive use wrist pain injury from her work. [00:40:46] Speaker C: Yeah. [00:40:46] Speaker A: And we're getting great results. But she's only got 10 visits a year. [00:40:51] Speaker C: Yep. [00:40:52] Speaker A: And so we've been doing twice a week for the last three weeks. So we got six visits in. The pain is almost gone. But I would like to do like stay on the two a week schedule. I told her I was like, we should stay on the two week schedule. She's taking herbs, which are helping a lot too. And in the last conversation she's like, well, I've only got four visits left and there's still, you know, three months in the year. And so I'm wondering if maybe we can like space them out. [00:41:18] Speaker D: Right, right. [00:41:19] Speaker A: And so this is such a classic conversation. Right. Like, can we space them out? And of course, like, you and I are really good at steering the patient's treatment plans at this point. You know, someone says to me, can we space them out? And I say no, because I. No, from my point of view, no. I would say let's do two more, that'll be eight, and then we can start to space. But like, I'm not done with this yet. I need the density of the treatment. [00:41:44] Speaker B: If we start to space the treatment now, then it's possible and likely, given the experience that I've had, that the symptoms may start to come back. [00:41:55] Speaker A: Exactly. [00:41:55] Speaker B: We don't want that to happen. We want to get to a shelf where it's not going to recur even if it's not completely resolved. We want it to be on a, like a flat, flat ground, so to speak, where it's not going to roll back downhill. [00:42:09] Speaker A: Exactly, yeah. Yeah. Sort of like an established landing point. [00:42:13] Speaker D: Right. [00:42:13] Speaker A: And we're very close to it with this patient, but we're, we're just not quite there. And so I want my next two. I want to knock it out still. Two more acupunctures in the week. Again, she's taking herbs in the background. This patient happens to respond very well to acupuncture, even local acupuncture, which I think is very cool. So that's why we've been using it in that way. I've seen her, you know, over the years. But this is kind of what I mean, like, all of a sudden, the dimension of the insurance, like, what's approved, how much it costs, how many visits, that's now invading into the treatment space. Because we have to consider, well, what's covered, what's not covered, for how long. What if I need more visits later? Because that's what she's thinking. Right. Like, well, I mean, my pain's mostly gone now and I got four visits left, but what if it comes back in a month and I only have one visit left? How will I get treatment? Because the natural assumption is that if I'm out of visits, I'm done. [00:43:09] Speaker B: I can't. I can't get more treatment. [00:43:10] Speaker A: I can't get more treatment. Which, of course is not true. [00:43:12] Speaker C: Yeah. [00:43:13] Speaker A: And in fact, like, with many insurance contracts, this patient would be able to get treatment just not at the copay price. They would get it at the contract price. [00:43:23] Speaker D: Right. [00:43:23] Speaker A: So, like, however much the insurance was going to pay me after copay, plus whatever they were going to pay me, that's now what she would have to pay. Right. The full amount. So it's still cheaper probably than our cash rate, but it's more than 20 bucks or whatever it is that she's been paying. So people go into this kind of conservation mode, which, if you're not careful as a clinician, you can. Because obviously we want our patients. We're not trying to bankrupt our patients. We want to be mindful of what stuff costs. We want to be good stewards of their time and their money. But you have to be very cautious to not let that awareness diminish what you think is actually necessary for healing. [00:44:02] Speaker B: Well, and what happens when you have more experience, I think, is because in the beginning when you're starting off, you don't really have a sense for that. [00:44:09] Speaker A: That's like, you don't know, how long should this. [00:44:12] Speaker B: How long should this take? How much treatment is this person going to need so that they're not going to slide back downhill. [00:44:18] Speaker D: Right, right. [00:44:19] Speaker B: But as you get more experience, you see, oh, we ended too early. And now, now it's two months later and it's like they're back to square one. [00:44:29] Speaker A: Yeah. And there's so much work to do and you don't have those visits anymore. [00:44:33] Speaker B: Now you don't have those visits. Yeah, exactly. [00:44:35] Speaker A: The hole is deeper in some ways. [00:44:37] Speaker D: Right. [00:44:38] Speaker A: And so it's harder to do the work. So, yeah, sticking with it until now, how will you know? Well, there's like, well, how would I know how long. There's no good answer for that. You listen to shows like this, you talk to people, have more experience. You. You collect your own data. I mean, it is, it is a. There is a reason why people who have more clinical have a better handle on this stuff than newer people. Like, it's not your fault if you're new. That's just the nature of it. But it's also not just a blank thing. You don't just have to wait until you have four or five years. You can talk to people. That's one of the ways you find out. But even still, you can find yourself being sort of led by the nose of these conditions of insurance. The thing is, here at root and branch, we take a lot of insurance as, as TC said, because in Oregon and Portland specifically, many, many if not most people who have insurance have acupuncture benefits. [00:45:31] Speaker D: Right. [00:45:31] Speaker A: There are hundreds of providers in Portland, many of which, again, probably most of which take insurance. So there's like a business market pressure to take insurance, because if you don't, there's probably five practitioners within a mile of your clinic who will. And so then you're like, well, I don't want to miss out on that business. I want to get in it. Even though virtually every insurance plan pays worse than you would get paid if you got. If you were doing cash. [00:45:54] Speaker C: Oh, yeah. [00:45:55] Speaker A: And you have to wait six weeks. And it's paperwork and you know, everything that everyone dislikes about insurance, but nonetheless, we take it and other people take it. Of course, over the years, we've taken less of it. [00:46:07] Speaker C: Yeah. [00:46:07] Speaker B: We take less and less of it. [00:46:09] Speaker A: Less of it because. Well, because it's annoying. [00:46:13] Speaker C: Yeah. [00:46:13] Speaker A: And when we do the calculus for like, how often do I get paid the amount I should get paid, how many hours have to be sent, tracking it down. We've just decided that it's worth our time to do less of it. [00:46:24] Speaker D: Right. [00:46:24] Speaker A: And if we can make it up in other ways without a pocket payments, that is cash payments. When you hear us say cash, I don't mean like literal cash. I just mean like, not insurance. [00:46:32] Speaker D: Right. [00:46:33] Speaker A: Most people pay with a credit card. We figured out a way to pivot that. But nonetheless, we deal with it all the time. And it's an interesting circumstance because, of course, insurance doesn't pay for herbs. [00:46:45] Speaker D: Right. [00:46:46] Speaker A: It doesn't pay for an herb consult. [00:46:48] Speaker D: Right. [00:46:49] Speaker A: So you know how you've designed your business. There are people out there who do a real stark Division between acupuncture office visit, acupuncture treatment, herbal office visit, and herbal treatment from an invoicing point of view. [00:47:02] Speaker C: Yeah. [00:47:03] Speaker A: Where they don't talk herbs in an acupuncture office visit because that's what the insurance is paying for. They're not paying for your herb time, so we're not doing it right. And then they pay for the actual treatment and then they just cash bill for the other stuff. We don't do that. We're a little more de. Generous, I guess maybe I don't know what the word is. This is just sort of how we do it. I don't know if it's generous or not, but we of course talk herbs in the acupuncture visits because those things go hand in hand for us. We use them together all the time, so why wouldn't we, you know, and the patient still has to pay for the herbs out of pocket, but the insurance is going to pay for the office visit. And the acupuncture itself, it's a little bit of a fusion thing. There's a lot of different ways to manage it. And we do hour long appointments, right? [00:47:47] Speaker C: Yeah. [00:47:47] Speaker B: We've moved away from every insurance payment situation that wouldn't justify an hour of time. [00:47:54] Speaker A: That's right, yeah. So insurance companies whose total payments, like limited number of codes and billing and stuff, whose total payments are less than, less than, substantially less in some cases than our average hour compensation. We've dropped those. Yeah, we tried a whole thing. We do half an hour appointments, whatever. It just didn't suit the way that we worked. And so we've dropped those. Now, the reason that we're talking about all this sort of business stuff, which, which I guess is a somewhat of a departure from our usual herbal content, is because as much as we love the patient facing stuff, the academic stuff, the thinking through it all, the. The reality is that this is a business. We make our living from doing this work. And so you have to figure out as a practitioner how to structure your work in such a way that you can practice in the way that you want. So in this context, we're talking about practicing quota as a small town doctor, this closeness to people, the tracking of cases, watching disease elements and formulas change over time. In order to do that, you need time. And in order to have enough time, you have to make sure that you can get paid for your time. And so how do we deal with that? We've tried a lot of stuff over the years. What was the original thing? What do we call it? Was It. Treatment plans that people bought. [00:49:22] Speaker B: Yeah, yeah, treatment plans. [00:49:23] Speaker A: So we would just sell bundles, basically, and say, like, okay, if you come in to see us, it's 140 for a 90 minute initial. It's 115 for a 60 minute follow up. But if you buy six appointments, the initial 140, and five follow ups together in a bundle, we'll give a 20% discount. [00:49:42] Speaker D: Right. [00:49:43] Speaker A: And it would make like the average appointment cost, like 90 bucks or something. [00:49:47] Speaker B: Yeah, 92 or something. [00:49:48] Speaker A: Yeah, $92. And we did that for many years. And that worked because if we also. Because, you know, I'm a big numbers nerd. And so I would sit down and crunch data from our clinic all the time. And so, like, our average insurance payment for an hour's worth of work was about $94. And so with our treatment bundle discount, we're coming in at $92. So like, you know, we're getting paid roughly the same for an hour of time, you know, but the truth is, it's like, it's hard. It's not a lot of money. [00:50:18] Speaker D: Right, right. [00:50:19] Speaker A: For the amount of work that we're doing. And so it's like, okay, how did, how do we pivot that? So over time, we then shrunk treatment plans, made them shorter or made the buy larger. So six wasn't enough. You had to go to eight. And it just, it got really sticky, which sort of. [00:50:34] Speaker B: Well, and it runs into a similar issue with the insurance visits approved. [00:50:39] Speaker D: Right. [00:50:39] Speaker B: So let's say the, for the first four of the six or four of the six of the eight, you're doing treatment, people are not too worried about it. They've already paid for those visits. [00:50:51] Speaker D: Right. [00:50:51] Speaker B: And in bulk. So. But toward the end of it, they're like, oh, you only have two visits left, so can we stretch, can we stretch them out? [00:51:00] Speaker D: Right. [00:51:01] Speaker B: And then it's like, well, in this case, no, no, we can't. We can't. We really shouldn't. We can, but we really shouldn't. [00:51:11] Speaker A: Right. [00:51:11] Speaker B: And in some cases you're like, okay, yeah, like, I think we could stretch them out in this, in this point, but I think we both have an aversion to that dynamic. Like, we grew an aversion to that dynamic over time. [00:51:24] Speaker A: Well, because it started to feel like, like there were factors beyond patient care that were shaping the decisions we're making. [00:51:30] Speaker D: Right. [00:51:31] Speaker A: And I don't, I don't like that. I don't know any clinician of any stripe who likes to be limited in patient care. Based on things like approved visits, codes covered, dollar allowed. [00:51:45] Speaker D: Right. [00:51:45] Speaker A: Like, nobody wants that. Like, you want to be able to give patients what you think they need and not worry about the cost. [00:51:51] Speaker B: Absolutely. [00:51:52] Speaker A: The problem, of course, is like, this is what has led to much of the trouble we have now because doctors, mainstream doctors in emergency departments or in, in primary care offices are saying, like, yeah, well, I need a CT to see what's going on there. Well, doctor, how much does the CT cost? Says, well, I don't know how much it costs, but I need one. [00:52:10] Speaker D: Right? [00:52:11] Speaker A: And there's been a, there's been an ignoring of the, the actual dollar reality. And so now there's. So then there's a pushback where we say, like, no, no, no, we need to itemize everything. People need to think through the dollars. Like, we need to be clear about the cost because then people get saddled with crazy bills that they can't pay. [00:52:28] Speaker D: Right. [00:52:28] Speaker A: And there's a natural question to go like, well, did you really need that test? [00:52:32] Speaker D: Right. [00:52:32] Speaker A: Did you actually need to come in for these visits? And now we're having, like, such a much more complicated and frankly, like, like a bad faith discussion, right, where we're assuming that doctors and hospital systems and billing departments are acting in bad faith, not in the patient's interest, but in the financial interest. [00:52:54] Speaker B: Yes. [00:52:55] Speaker A: And the thing is, is that some of them were right? And so, and are. This is not a fixed problem. So it's, it's really sticky because this, you know, we think, oh, that's what's happening in the, in the big hospitals. Why would that affect us? But it affects us because everyone's thinking it, right? Patients are walking around with this programming from their everyday doctor interactions that then spills over to us. And there's a totally understandable question of like, well, this is my money. I need to make sure I'm getting my money's worth. Is this necessary? I bought these six visits, but I'm feeling pretty good at four. But my doctor says, no, I gotta come in for these two. Is he just saying that because he wants me to use up my treatment plan so I buy another plan? That's a reasonable question to ask, right? You know, because that is stuff that does happen. [00:53:39] Speaker D: Right? [00:53:40] Speaker B: And the other thing. So we're sort of moving towards the inevitable, the, the inevitable move that we've made in the past year toward a membership model of treatment which we want to talk about. But I have a story of an, of a case example that really made this clear for me earlier. Actually, it wasn't this year. It was maybe last year or something like that. But anyway, we have, as we've talked about before, we have a residency program at Rudin Branch and we had a patient come in and see one of our early residents. It must have been more than two years ago then. [00:54:18] Speaker C: Yeah, yeah. [00:54:20] Speaker B: And this person came in for combination of knee pain and low back pain. But the knee pain was really, really bad to the point where they couldn't work. This person, this patient worked with children and like a kind of a daycare type center. [00:54:38] Speaker A: Yeah. [00:54:38] Speaker B: And she couldn't work. That's how bad the pain was. And so she came in to see one of our residents and our, our resident treated this patient twice a week for I don't know how many weeks. I think it was four weeks or something like that, a full month. And the pain was getting better, the pain was improving. And this patient basically could go back to work at that point. So she went back to work. During this time the residents left. We transit. This is like during the time when they're leaving in the cycle. [00:55:15] Speaker A: They're finishing the program here. [00:55:16] Speaker B: Finishing the program here. About a month later, the patient had a flare up of the pain and she came back in, but this time to see me. [00:55:26] Speaker D: Right. [00:55:27] Speaker B: And so I did the assessment and the differentiation and I treated her. And she said when she came back in that she was extremely worried because she had used eight of the nine visits, like this was the ninth visit that was she was going to be have to use to treat the pain. And the pain was, she felt like just as bad as it was when she started coming in. So after, after this time. So I treated the patient using the method that I was using at the time, which happens to be the thing that I now teach the residents for the acupuncture side of the curriculum. And in a single treatment, this patient got as much benefit out of that one treatment as she had gotten from the previous eight treatments that the resident had done. [00:56:17] Speaker A: Right. [00:56:17] Speaker B: When, when the resident had treated her and she didn't need to come back in for treatment. I didn't see her for I think another eight months. And then she did something that tweaked it a little bit and we treated it again or whatever. But I, I bring that up for a couple of reasons. The first one is the better you get. So. So I've had plenty of cases just, just so it's not a, this isn't an ego thing. I've had plenty of cases of people where I haven't been able to help Them with my acupuncture, my herbs. So this was a case where my interpretation was the area that the person was treating was the wrong area. The pain wasn't actually a knee problem for this patient. The problem was in the patient's low back, and it was referring to the knee. And what the resident did was treat the knee like he stem the crap out of the knee and forgot about the back. And what's interesting is the patient still got better, right? [00:57:13] Speaker A: Sure, yeah. [00:57:13] Speaker B: So there was still improvement, but because I think I was able to find the area that actually had the problem and treat it effectively, the patient was able to recover much faster. The other side of this, though, is that the amount we got to bill. So just from a financial perspective, the amount that we got to bill for that one session versus the amount that that resident got to bill for treating that patient. Eight times. Eight sessions. [00:57:44] Speaker A: Yeah. [00:57:45] Speaker B: Is a huge difference. [00:57:47] Speaker A: Eight times different, in fact. [00:57:48] Speaker B: Eight times different, in fact. [00:57:50] Speaker A: Yeah. [00:57:50] Speaker B: Including the initial right assessment, which is. [00:57:54] Speaker A: Worth revals and revals, all of that stuff. [00:57:58] Speaker B: So what we realized was. What I realized after thinking about this was the better you get at the medicine, potentially, the faster people get better. [00:58:11] Speaker A: Right. [00:58:12] Speaker B: But if you're not careful, the way that you set up your business, the less money you make. [00:58:18] Speaker D: Yeah, right, right. [00:58:19] Speaker A: I mean, this. So let's consider this dynamic. Right? If you're better at treatment, people get better faster. They need fewer treatments. And assuming, you know, that you are continuing to learn and train and improve, this is the trajectory for all of us. [00:58:35] Speaker D: Right. [00:58:35] Speaker A: You know, the more time you spend in clinic, the less time patients need to get better. Because, frankly, you're just better than you were five years before, 10 years before. But how do you deal with that financially? [00:58:46] Speaker D: Right, Right. [00:58:47] Speaker A: And the problem is you don't want to be in a situation where you are now, like, dancing against a kind of ethical conundrum. [00:58:55] Speaker B: Exactly. [00:58:55] Speaker A: Where you're like, oh, well, I mean, they're better, but they're not perfectly better, so let's have them come in for another visit. [00:59:02] Speaker D: Right. [00:59:04] Speaker A: That is not a place you want to be. Exactly where you're having to evaluate for yourself. Like, wait, is this a real thing? Or am I just trying to milk the treatment here? [00:59:12] Speaker D: Right. [00:59:13] Speaker A: Because now you're. You're rapidly positioning yourself into a place that can become wildly problematic from a fraud point of view, from an exploitation point. I mean, it could just get nasty so quickly. [00:59:24] Speaker C: Yeah. [00:59:24] Speaker A: But at the same time, we have to recognize that, like, you used to get paid eight visits worth of treatment and now, you get paid one, or let's say two. [00:59:32] Speaker B: Right, Exactly. [00:59:32] Speaker A: Do it in two. How do you make up that difference? Well, you can see more patients. That's the simple way. So the sort of very generous line of logic here is that, well, you're doing so much better, you're a better clinician, you help more people, they tell more people. So even though this one patient, you only billed two visits, you saw three new ones in the same time, and you also build them two. [00:59:54] Speaker D: And. [00:59:54] Speaker A: And now there's your eight visits. [00:59:56] Speaker D: Right, Right. [00:59:56] Speaker B: And. And this patient, like, has a. Obviously, now we have a great rapport because of these results. [01:00:03] Speaker A: Sure. [01:00:03] Speaker B: But this is an. This is an example of a patient, despite all the typical rhetoric around, like, you feel better, don't hesitate to reach out to people and let them know the work that we're doing, all of this kind of stuff. This patient's never referred another patient to our clinic before. I know that for a fact. [01:00:20] Speaker A: Well, yeah, we track it. [01:00:21] Speaker B: We track it. [01:00:22] Speaker A: Yeah. We track how people make their way here. So we're. We're pretty clear about how people find themselves to us. And that, I would say, is normal. [01:00:29] Speaker B: It is normal. [01:00:30] Speaker A: Most people are not referral sources like Mac was. [01:00:33] Speaker D: Right. [01:00:33] Speaker A: I mean, that's exceptional in every way. And, you know, everybody, every Clinic should have 2, 3, 4, 5 seed patients like Mac. That would be amazing. And each of those maybe give you another seed, and boom, it just grows. But the truth of the matter is, from my opinion is that is luck. [01:00:50] Speaker C: Yeah. [01:00:50] Speaker A: Like you being an excellent practitioner. And whether or not someone like Mac walks into your clinic is luck. There's no. So it doesn't matter how good you are. We happen to have had someone like Mac walk in, so. [01:01:03] Speaker D: Great. [01:01:05] Speaker A: So the thing is that when Travis and I started really looking at this, we run lots of numbers annually. I do a massive report analysis of our whole clinical operation and our pharmacy medicine operation. And I just crunch a bunch of numbers looking for some key metrics. I want to know, you know, some basics. How many patient visits did we have? How many unique patients? How many patient visits? What's the average insurance price? What's the average cash price? Whatever. What. How many herb formulas do most people get? How much money do they spend on average on those formulas? Like, these are the data points I'm looking for. But once you have those kind of big level data points, you can start to then also combine them in ways and say, like, okay, well, when a person walks in off the street to see us, for whatever reason, cash Insurance, whatever. They're just, they found us, they want treatment. How many visits is the usual number of visits that a person comes in for? Number one. And how many dollars is that unique patient worth right now? If you are one of the very many people in life, and particularly in our profession, who is uncomfortable with money talk, yeah, right. But this is a warning. We're going to talk more about money. I will say, if you're that person, I totally get it. But I will also say that in our culture, money is the way that we confer value and it has its own kind of chi quality that it's important to understand. And that if you can set up systems in such a way that are sustainable for you and your business, then you can be generous, you can be community oriented, you can be supportive, which. [01:02:46] Speaker B: You can't be if you don't know. [01:02:47] Speaker A: If you don't know, and if you. [01:02:49] Speaker B: Work for someone else, let's say this is happening anyway, whether or not you think about it, somebody else is thinking about this kind of thing. [01:02:56] Speaker A: Absolutely. And the more that you know about it, the more you can shape your business to align with your values and to align with your goals. But if you don't know the numbers, then you can't make those choices. You're just guessing, right? If you don't know how to get those numbers, send me an email. I will help you. I love this stuff because I just, I think it's actually really empowering. I think that people are scared of accounting and scared of, of Excel. I get it, it's lots of numbers and stuff. It's scary, but once you crack it, it's not hard. It's specific work, but it's not hard work. And once you crack it now you have so much power over the shape of your business because you understand it. So we crunch all these numbers and we derive that. And I took the data over a three year period because we didn't want to have just one year. Because our business, like most people's business, grows a little bit every year. And so you need to kind of look at sort of over time. And so what happened was, is we said like, okay, well, a patient off the street, on average. Now again, average is not always the best number. Because we have some people like Mac, who came in here twice a month, every month. We have some people who come in once and never come back. So, you know, sometimes you need to look at median numbers, sometimes mode numbers. You can get at stat stuff, whatever. It's nerdy, but we'll go with Averages, on average, a person, a new patient to us, someone we've never seen, comes in off the street. They come in for seven visits. They spend $720 on clinical costs, and they spend $300 on herbs. That's what the data shows over three years. So basically, a patient is worth about $1,050. Like a person just walks off the street. Thousand and fifty dollars. It's not that much. [01:04:33] Speaker D: Right. [01:04:34] Speaker A: And so if you want to make a living with two people and pay employees and stuff like that, you got to see a lot of patients if they're on average just worth a thousand dollars. [01:04:43] Speaker D: Right. [01:04:43] Speaker A: That's quite a lot of patience, actually. So we were like, okay, well, if this is how it's worked out and we're getting paid what we get paid, which is, you know, not. We're certainly not buying maseratis over here, but we pay our bills, we're doing okay. And. And so if we're like, okay, if. If we want to do at least as well as we're doing now and better, can we design a system that allows us to make that same amount of money per patient, make it cheaper for the patient's experience, and it remove this piece where people are making decisions about their care based on how many. [01:05:21] Speaker B: Visits they have and care prematurely? [01:05:23] Speaker A: Exactly. [01:05:24] Speaker B: All of that kind of stuff. [01:05:25] Speaker A: So here we are. We're aligning our business interests, the patient's financial interest, and the patient's outcomes. And so that's when we're saying, like, okay, well, what can we do that? So we ultimately landed on an idea for a membership plan, which is something we had heard. I mean, years ago, when we were in school, people were talking about membership plans. But usually, in my opinion, people try to make membership plans with a kind of business logic that makes sense on paper but makes it not accessible for patients. So they'll say something like, well, you know, the average cost of a return visit is $115. Let's say, you know, people came in once a week, which is how people come in. Right. That's worth $460 if they came in once a week. So I'll give them a discount, and they can get membership for $350, and it's a maximum of one visit per week, and they're saving a hundred bucks. What a great deal. Right? And the thing is, is that, like, you're not wrong assuming that people came in that much. But in our market here in Portland, $350 a month as a membership plan just doesn't sound Very generous. It sounds expensive. [01:06:33] Speaker C: Yeah. [01:06:34] Speaker A: Right. So how many people are picking that up? $350 a month. And how are you selling it? Like, what's the catch? How are people going? Like, oh, wow, that's a really good deal. And everything is a subscription these days. Like literally everything is a subscription. So people are a little bit. What's the word? Like, cautious around another subscription in a way that I don't think they were a decade ago. [01:06:58] Speaker D: Right. [01:06:58] Speaker A: But now they are. And so now your subscription needs to look really clean and really appealing. So we ultimately landed on a subscription that said that it's $199 a month with a six month minimum commitment. [01:07:14] Speaker D: Right. [01:07:14] Speaker A: So you're on the hook with us for six months. You're going to pay this 199amonth for six months. And with that price, you can come in for as much acupuncture and as much nutritional consultation as you want. [01:07:30] Speaker D: As. [01:07:30] Speaker B: As you need. [01:07:31] Speaker A: As you need. That's the way we phrase it. That's right. Not as you want, because we tell people what they need. [01:07:36] Speaker D: Right. [01:07:36] Speaker A: But as much as is needed. Right. As much treatment and as much. And nutrition as needed. And that distinction, by the way, want and need is actually important in your. In your marketing because we need to always remember that we are the professionals in the room. And while we're not forcing anything on patients, we need to always tell patients what we think they need. [01:07:55] Speaker D: Right? [01:07:55] Speaker A: Right. So if you need to be here weekly, great. You need to be here bi weekly, great. You need to be here twice a week, great. Like, whatever it is, we need to tell them. But this plan was like, look, you pay 199amonth and you get as much treatment as needed for your career. And this was very significant. Now that tariffs have been in place and the price of herbs has gone up, 40% for us is you can get your herbs at half price. Now we run the medicine area, so we have the ability to offer that as a benefit. And so when you're looking out, if someone comes into us off the street and they're like, I've got a condition, I've had for 10 years. I've had IBS for 10, 15 years. I've got constipation for three years. I've been an insomniac for 15 years. We know because we've been doing this work long enough. This is gonna take months to fix. [01:08:39] Speaker C: Yeah. [01:08:39] Speaker A: Like, it's gonna take like a minimum of two months to even know if this is a good intervention for you. And probably another four after that to really make change. But we also know that in that time, people are likely to see us very frequently in the first eight weeks, once a week, every week for eight weeks, maybe, maybe 10 weeks. But then at some point they're gonna need less acupuncture treatment because this, the pattern has shifted and they're taking the herbs in the background. And so they're going to come in every other week in the third month, and then maybe once every three weeks through the rest of their initial membership plan. And so the total number of visits that a patient is coming in for is not swamping our schedule. [01:09:18] Speaker D: Right. [01:09:19] Speaker A: Because eventually it starts to stretch out. But we're still getting paid. Right. $199 a month, which isn't much. I mean, it's on its face, it's not much. But the total value of that patient is now a minimum of $1,200 in subscription fees, which is more than the total amount that a new patient was worth to us, including herbs. [01:09:41] Speaker D: Right. [01:09:50] Speaker A: And also they're going to buy their herbs from us, admittedly at a 50% discount, but that's going to cover most of our cost of goods and most of the labor to produce them. So we're not losing money on the her. And that's also revenue that's coming in. And so when you look at the actual value of a patient now in that six month period, what we've seen in our test program is that people are using us for roughly the same amount of visits, somewhere between like 7 and 10. So slightly more than the total average, but not so much more compared to the cash average that we saw before. It's problematic, at least at the moment. And the dollar amount that each of those patients is worth is actually closer to like 1700 as opposed to 1050. [01:10:33] Speaker D: Right. [01:10:34] Speaker A: So this. [01:10:35] Speaker B: And the results have been better. [01:10:36] Speaker A: And the results have been better. This is of course the thing. Right. We're talking about the business side of it. But the patient has a fixed dollar amount. They know what their costs are. A 50 discount on herbs means their weekly herb cost is somewhere in the like $20 range, $25 range, which is very manageable for the population we work with. And then they're feeling so much better. [01:10:56] Speaker C: Yes. [01:10:57] Speaker A: And because they have the membership, they call us first. [01:10:59] Speaker C: Yes. [01:11:00] Speaker A: Oh, I've got a cold. Can we help with that? I've got a cough. Can we help with that? In a way that those same people may have come to us eventually, but after they'd done like three rounds of Antibiotics. And nothing worked. [01:11:10] Speaker C: Yep. [01:11:10] Speaker A: And now it's like, oh, my gosh, we can actually intervene rapidly in acute condition because people are like, well, I'm paying for the membership, so. [01:11:18] Speaker D: Right. [01:11:18] Speaker A: It doesn't cost me anything to go. [01:11:20] Speaker D: Right. [01:11:21] Speaker A: Combine that with the fact that we use an EHR system that stores cards on file. And so the whole interaction at the clinic is moneyless. Yes. Right. They're getting billed monthly on a recurring stream, and then we use the card on file for their herbs, and they get, you know, invoices and receipts and stuff, so they know how much it's costing. But, like, there's not the checkout process. They're not paying us money. [01:11:46] Speaker D: Right. [01:11:46] Speaker A: There's a. There's a. A divorce that's happening between what this costs and what I'm getting. And what I'm getting is so incredibly outstripping any question of cost. And yet, even when I look at cost, it's kind of low that I feel like I'm getting as a patient. Value beyond measure. [01:12:03] Speaker D: Right. [01:12:04] Speaker A: And that is amazing. [01:12:05] Speaker C: Yeah. [01:12:05] Speaker B: And that's the experience you want people to have. [01:12:08] Speaker D: Right. [01:12:09] Speaker B: You want people to be enthusiastic, ecstatic about what you're offering. [01:12:14] Speaker A: And we're doing it in a way where it's also not giveaways. People, they have a contract for the program. It costs money every month. They see it coming out. They still pay for herbs when they come in. Yeah. [01:12:24] Speaker B: There is a commitment. [01:12:25] Speaker A: There's a commitment. Right. This isn't just like, oh, I give away free treatment sometime. Because what we've also seen is when we do pro bono work, you have to be very selective about how you do pro bono work, because you can end up doing a lot of free work that doesn't even help the patient because they weren't able to commit to. Because there wasn't this dollar accountability question, you know? And maybe if we lived in a different world, that wouldn't be the way dollars work, but it is how they work. And so leveraging that to your patient's advantage to say, like, hey, you've. You've spent the money. Let's make this happen. And no longer a question of, well, can we stretch out the visits? [01:13:00] Speaker D: Right. [01:13:00] Speaker A: Doesn't matter. Just come in. Like, I need to see you. So come in. [01:13:04] Speaker B: And if people get better faster. [01:13:06] Speaker D: Right. [01:13:07] Speaker B: It serves the clinic right, because then they don't need to come in as often. [01:13:12] Speaker A: Right. [01:13:12] Speaker D: Right. [01:13:12] Speaker B: And so then, oh, yeah, you can come in next month. And it's. That's all you need. You don't need to come in every week. And then there's more. So the, the, let's say the refinement of your skills as a clinician has a positive outcome to your business as well. [01:13:29] Speaker A: Exactly. [01:13:29] Speaker B: Financially. [01:13:30] Speaker A: Exactly. Because now people know that they can get really good results quickly. But you don't have to worry, like, gosh, I'm helping these people so quickly, I'm not getting paid. [01:13:39] Speaker D: Right. [01:13:40] Speaker A: And so, you know, this is still the first six months of this program. We just launched it earlier this year. And so we're tracking the data. Right. I mean, like I said, I'm a data person. But the initial results are very compelling, which is why we're talking about it to you guys now. And once we have a year's worth of data and I can go and compare it and do all my number crunching and stuff. So like, sometime in June of 26, then I'll be able to put something together that will. Will publish. Like, we'll let people know, like, hey, this is how we did it. This is the numbers, this is the pricing. This was the logic. So that way people can see, okay, are there alternative business models for me, right. Where I can get out from underneath the thumb of insurance, I can get out from the can the limiting control of things, like how many visits do I have left? And patients can get better faster. And so I think this is. There's really something here, and it's something that interests me because we're in an inflection point in Chinese medicine where a lot of stuff's changing. Schools are continuing to close, the cost of school is not getting any cheaper, student loan situations have constrained available money, and it's difficult in many ways to make of living in this business. And I keep thinking to myself that, you know, we've spent so much time in the last generation of, of Chinese medicine practitioners, say the last 20, 25 years, really trying to get at the table, get a seat at the table. We are legit. We are yahoos. Like, we should be covered. Acupuncture is cheaper, better, faster than knee replacement. Like, give us the money. And that has resulted in. In there being acupuncture coverage, which is really remarkable in a lot of ways. But the downside is that we're still not a valued member of the table. I'm not even sure if our seat is exactly at the table. I think we're in, like, the kids table table. [01:15:29] Speaker D: Yeah. [01:15:30] Speaker A: Over at the side. And if we try to say something about something, at the adults table is like, kids table. [01:15:35] Speaker D: Right, right. [01:15:36] Speaker A: If, you know, if you don't know your place, you're not going to get dessert. Like, there's a kind of. We're constrained in that position, and I don't see a lot of evidence that, that that is improving. In fact, I think it's the opposite. I think I see payments getting cheaper, like, they're paying us less. The medical necessity review is getting worse. The paperwork is getting more intense, the amount of time that gets spent on it, and I don't like that. [01:16:04] Speaker D: Right. [01:16:04] Speaker A: And you know, we do our own billing here. A lot of people don't. They. They use a biller and stuff, which is great, but we do, because I like to stay connected to what's actually happening. And. And it's getting harder and it's getting more. It's getting less profitable. So maybe we need to try something different, is my point. Like, instead of being like, hey, let's see if we can get the insurance yet again to pay us more and give more visits. Like, what's it in? What's in it for them? Like, we don't. We don't have any power here. Like, oh, read this study about how much better acupuncture is than knee. Okay, man, sure, whatever. Like, why is that going to make them pay us more? How much energy you gonna spend on that? I wanna say, why not let us try new stuff? So, like, we run a pilot membership like this. Other people are doing other interesting structures, payment structures. How are you doing it? So this is a call to anybody listening who works in a clinic that has a different payment model. Maybe you guys are doing membership, maybe some kind of cooperative, maybe some advanced treatment plan bundle. Something we want to hear from you. Tell us what you're doing. Yeah, because I think that if we're going to survive as a profession, we're going to need to be crafty. We're going to need to work together more than we have really in a long time, maybe ever. You know, everyone's. We're a bunch of weirdos in this field, right? Like, people that got our opinions about stuff. And maybe we don't always play together well. And I'm not saying we all need to be best friends, but I do think we'd all like to make a little more money and help our patients a little more. I haven't yet met a Chinese medicine practitioner who's like, nah, I don't want to make any money and who cares about patients. That's not a thing, at least as far as I know. So I think we could at least agree on that. And I think we could test these kinds of things and then talk about them, publish them, discuss them, give people templates to test out, get feedback on. Because what I feel very sure about is that if we keep doing things the way we've been doing them, I don't know that we're going to survive the next 20 years as a profession. Yeah, I don't think we will. And so we got to be crafty. So we got to. In some ways, it's sort of back to first principles. Right. The subject of the show, working like a small town doctor, that's a look back. But looking back doesn't mean we have to just forget about what's also working today. [01:18:20] Speaker D: Right. [01:18:21] Speaker A: It's the thing that's the most Chinese medicine thing, in my mind, most Chinese cosmology thing ever, which is like, what's working here? Let's take all that. Yeah, we're going to leave the stuff that's not working. We're going to take the stuff that is working. It doesn't matter where it came from, doesn't matter whose idea it was. We're going to pull it together, we're going to digest it, and then we're going to try a thing. And so hopefully we can actually get there. [01:18:42] Speaker C: Yeah. [01:18:44] Speaker A: All right, well, that's the end of our soapboxing for today, but hopefully it was a useful discussion on some levels, at least to think about how we do business and how we interact with patients. As always, we appreciate you guys listening to the show. And if you want to rate and review it anywhere that you listen to podcasts, it's always good for us. It helps other people find the show. And if you want to answer my call to let us know how you guys are doing, practice. If it's a different way, an innovative way, something you think we should hear about, send us a message@the nervousherbalistmail.com thenervousherbalistmail.com and also to if you've got any suggestion for shows, we're open to hearing about that. So we appreciate you guys listening and we'll talk to you next time. [01:19:25] Speaker B: Yeah, we'll talk to you next time.

04-04 Working Like A Small-Town Doctor

Show Notes

Episode Transcript

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