0:42

Primary care is an innovative, alternative

0:45

path to insurance driven health care. Typically,

0:49

a patient pays their doctor a low monthly

0:51

membership and in return,

0:53

builds a lasting relationship with their doctor

0:55

and has their doctor available at their

0:57

fingertips. Welcome

0:59

to the My DPC Story podcast, where

1:02

each week, You will hear the ever so

1:04

relatable stories shared by physicians who

1:06

have chosen to practice medicine in their individual

1:08

communities through the direct primary

1:10

care model. I'm your host, Marielle

1:13

Conception, family physician, DPC

1:16

owner, and former fee for service doctor.

1:19

I hope you enjoy today's episode and

1:21

come away feeling inspired about the future

1:23

of patient care, direct primary

1:26

care.

1:29

Direct specialty care is the opportunity

1:32

to make medicine yours, your style,

1:35

your terms, your relationships. I

1:37

am Dr. Begaris, and this is my direct specialty

1:40

care story.

1:46

Dr. Fred Bagares s a board-certified physician

1:48

in both sports medicine and rehabilitation

1:51

medicine. His clinical interests include

1:53

biomechanics, rehabilitation medicine,

1:55

pain science, spine care, electrodiagnostic

1:58

medicine, musculoskeletal ultrasound,

2:00

and medical education. After

2:03

medical school, he completed his residency in

2:05

physical medicine and rehabilitation, or PM&

2:07

R, at Northwestern University Rehabilitation

2:09

Institute of Chicago, in addition

2:12

to a fellowship in sports medicine. Dr.

2:14

Bagares believes that movement is the key

2:17

to living. He is fascinated

2:19

by how diseases affect the way people move,

2:21

which lead them to his care. Coming

2:23

from an osteopathic medicine background, the

2:25

transition to both PM& R and sports medicine

2:28

was very natural. He has worked

2:30

in a variety of settings, including a multi specialty

2:32

surgical private practice, academic

2:34

medicine, military medicine, and also

2:37

solo private practice. In his spare

2:39

time, he enjoys spending time with his amazing wife,

2:41

Chasing his two children and practicing jujitsu.

2:46

Welcome to the podcast, Dr. Begaris.

2:48

Thank you for having me.

2:50

Fellow Filipino doctor in the house, super

2:52

stoked. One of the things that I wanted

2:54

to open this podcast with is that

2:57

we have not heard the story of a physiatrist

2:59

before. So can you start us off

3:01

with what is PM& R and

3:03

what does it mean to be a physiatrist

3:05

absolutely. So PMR

3:07

is a fairly small specialty,

3:10

but it is the medical specialty that manages

3:12

conditions and disorders that affect the way

3:14

people move. Typically

3:16

as a result from chronic, congenital,

3:19

orthopedic, or neurological diseases.

3:21

So our, kind of our bread and butter

3:24

has been like stroke care, traumatic

3:26

brain injury, multiple sclerosis,

3:31

amputee care. But over time

3:33

it's evolved into these various

3:35

subspecialties. So pain medicine,

3:37

sports medicine, hospice palliative

3:40

care. Pediatric rehabilitation

3:43

neuromuscular medicine as well. So it's, it's,

3:46

we're pretty much covering all

3:49

over the place. But most physiatrists, if they're not

3:51

in the Inpatient setting, doing acute

3:53

care rehab, a lot of them are outpatient

3:56

doing probably non surgical orthopedic

3:58

or, or pain medicine care. in

4:00

terms of the main difference between orthopedic surgery

4:03

obviously, the big obvious thing

4:05

is that we don't, we don't do surgery. A

4:07

lot of our care is really focused

4:09

on on different types of

4:11

injections. Some of us do EMGs.

4:14

A lot of it is, is looking at the overall

4:16

rehab picture. I think that's, that's

4:18

actually one of the big draws to

4:21

PMR. I was, I actually went into medical school

4:23

wanting to be an orthopedic surgeon. And

4:25

after a while, I just kind of was like, you know what, I kind of like,

4:28

I kind of like looking at everything and that just

4:30

kind of fits my personality. But that's

4:32

pretty much the, the big thing is, is that I

4:34

think overall orthopedic surgeons obviously do surgery.

4:37

Physiatrists also tend to, to

4:39

follow people further, further in their

4:41

life, which I think was also really important for me.

4:44

Now, with understanding what PM& R

4:46

is in relation to where it lives

4:48

in the medical specialty world, how it's not

4:50

orthopedics I wanted to ask

4:53

how your training was

4:55

to be able to to be

4:58

able to be a physiatrist in terms of

5:00

when you were in training, how what

5:02

kind of autonomy did you experience?

5:05

If any and how did that manifest?

5:08

Because with it being a smaller specialty,

5:10

I find sometimes that when people are like, Oh,

5:13

you want to do rural medicine? Like that

5:16

was my experience is like, create your own

5:18

curriculum and we'll sign it off. So I'm just wondering

5:20

about your training to be able to get

5:22

you to this point where you're like, yeah, man, I'm going

5:24

out on my own.

5:25

Right, right. My, my residency

5:28

was was amazing. I, I went to,

5:30

I did my residency with Northwestern,

5:33

formerly known as the Rehab Institute of Chicago.

5:36

And we had a pretty broad at

5:38

least back then, we had a pretty broad

5:40

scope of, of exposure. As

5:43

like, in terms of like the actual requirements,

5:45

inpatient versus outpatient versus

5:48

specialty rotations. I thought

5:50

we did a really good job, or

5:52

the program did a really good job of just You

5:54

know, laying it all out there. If anything

5:57

I think what I learned back then is that, all residencies

5:59

aren't the same. So, I definitely

6:01

ran across colleagues that had different experiences,

6:04

but I ended up the,

6:07

I ended up doing a fellowship after that.

6:09

I, I had a lot of training. I felt

6:11

really very comfortable as a general physiatrist.

6:13

So I, ironically, actually,

6:16

actually was planning on going into

6:18

kind of an inpatient. managing

6:20

spinal cord and neurological disorders

6:23

slash sports medicine, but there

6:25

wasn't like a real job for them at the

6:27

time. So I decided to go

6:30

to go on to fellowship to, to do

6:32

more in terms of learning sports medicine

6:34

and musculoskeletal injuries and electrodiagnostic.

6:37

But also more importantly I really wanted to

6:39

have interventional spine spine

6:41

skills. But overall,

6:44

it's, I think PMNR, because it is so

6:46

vast I think you definitely

6:48

have to have an idea

6:50

of what you like and what you don't like, like just

6:53

heading, heading in, because there's just,

6:55

I was kind of the guy that, I

6:57

wanted to do inpatient. At one point I wanted to

6:59

do a spinal cord injury fellowship. I thought

7:02

about pediatric rehab. I mean, I was like kind of all

7:04

over the place, which is as a resident was

7:06

great. Like. I was just excited about

7:08

everything. So, so I think

7:10

as a physicist, if you're interested in physiatry

7:13

or PM& R, you definitely have to be super

7:15

proactive because, again,

7:17

I'm 10 years out, so actually plus

7:20

10 plus years out. So I think the

7:22

options are probably, it might be almost too

7:24

many options at this point, but But I

7:26

think it's I think overall that that's

7:28

the way I kind of approached it is I just, every,

7:30

every opportunity I saw, I just kind of just went,

7:32

I just kind of went for it. But in terms of preparing

7:35

me to, to make this jump, nothing,

7:38

like, like I, I don't, I didn't know it

7:40

back then, but that I was going to be doing this

7:42

now, but I'm sure we'll get into that too.

7:44

So,

7:45

Well, that's that's great to hear because that was my

7:47

next question is, did you see

7:49

any doctors who are doing cash

7:51

pay physiatry while in residency

7:54

or in medical school? And just because it is,

7:56

a very small subspecialty,

7:59

compared to family medicine

8:01

or, the number of residencies out there is

8:03

what I'm speaking to. But,

8:05

the answer is no. And that's not

8:07

surprising. I, I.

8:10

Hope again that this changes in the future,

8:12

given what you're sharing today. Now,

8:14

let me ask you about your geographic location

8:16

because you are in

8:19

Virginia Beach, Virginia. And I'm just

8:21

wondering about what drew you specifically

8:23

to that area. And do you find physiatry

8:25

is something that is crazily

8:27

needed in your area.

8:29

So, we were in Chicago

8:31

at the time and I actually wanted to,

8:34

I didn't know where I wanted to go. And so I joined

8:36

a practice out in Vancouver,

8:39

Washington. Great practice,

8:41

multi specialty surgical group, but yeah

8:44

I'm an only child and my, and my wife is from

8:46

Is from Virginia Beach. I grew up in Northern

8:48

Virginia and all of the family was on the East Coast.

8:51

So I knew I wanted it.

8:53

We tried to get people to come out to where we were,

8:55

but you know, there's just too many. So,

8:57

we, we decided to move back eventually,

9:00

but it was actually kind of hard to,

9:02

to. to find a job in this

9:04

area, because I remember

9:07

distinctly when I was in fellowship looking

9:09

for jobs in this, in this locale,

9:11

just, just not exactly knowing

9:13

where I wanted to be, but I wanted to have options. And

9:15

it was it was hard, it was hard to find

9:17

to get callbacks. And I think at the time,

9:20

the year prior to me graduating

9:22

was a really big hire year. And

9:25

so I think people were still,

9:27

no one was hiring the next year, so, so

9:30

when, when I saw the opportunity, well, we were actually

9:32

on the, on the West coast

9:34

and my daughter

9:37

was like, like four or five years

9:39

old and she, all

9:41

of, all of the cousins are right around the same

9:43

age. So she started

9:45

asking, when's the next time we're going to see

9:48

my cousins again? And, you know, up until, you know, their babies,

9:50

like they, they don't remember, but now that they remember, I was like, Oh

9:52

man. You know how, I think

9:54

we got to move back. So like, I remember

9:56

I dropped her off at school and

9:58

I immediately started looking for jobs on the,

10:00

on the East coast. And it just

10:02

so happened that there was an academic position.

10:05

On the East coast, I apply, I mean, I literally applied

10:09

and just kind of went for it and got

10:11

the job offer and, and then

10:13

we ended up back on the East coast.

10:16

So let me ask you there because earlier, you

10:18

talked about how your residency was

10:20

amazing. You had so much exposure. You're

10:22

like, what do I not do in my practice

10:24

later on? And then you also talked about,

10:27

you're thinking specifically inpatient. When

10:29

shifted to, know,

10:32

the primary thing is that I need to be

10:34

close to family and I also need

10:36

a job. How did your narrowing

10:38

down of how you wanted to practice shift?

10:41

Like, did you? Just say like,

10:43

I'll be fine with whatever is open as

10:45

long as I can get a job because my family's

10:47

going to be in Virginia Beach.

10:49

Right. I really, my

10:51

priority at that time was to get my family

10:54

as close as possible. So that was kind of like,

10:57

once I knew that, that's, that

10:59

was not an issue. It was like, I just need to figure out a way

11:01

to do it. And then in terms

11:03

of like, is this a job that

11:06

I, we could, I could take, quote

11:08

unquote it really kind of came down to the

11:10

finances, like I remember, I remember

11:12

like kind of crunching the numbers and I

11:14

was never released financially, literate

11:17

up until basically like, right afterwards,

11:19

right after fellowship when I actually started, Oh, I

11:21

actually have to pay attention now. So, when

11:24

I, that kind of played a role into my negotiations,

11:27

because I was like, I knew the number that I needed

11:29

to, to, to safely, go back

11:31

and be able to pay my off my school loans and so

11:33

on and so forth. And so,

11:36

I guess it, it ever teach their own, like

11:38

just being home close, close to

11:40

parents was really, really important. And so

11:42

as long as I hit the number. Like,

11:44

I was like, I'm good. Let's just go.

11:47

I appreciate you answering that because

11:50

many people in medicine

11:52

when, they're with a

11:54

particular amount of loans after if

11:56

they're not going to a loan repayment program

11:59

because they're driven to move close

12:01

to family or move close to like where they want to practice

12:04

or whatever the reason is, and they're not getting,

12:06

Like guaranteed loan repayment and you're having

12:08

to repay with what you're making. I

12:10

think that's a very excellent thing for people

12:12

to hear in terms of your perspective on how you went

12:14

through choosing your

12:16

first job there. Because I will say knowing that

12:18

there is other jobs that came after. So,

12:21

In terms of this idea of

12:23

taking a, a, an employment

12:26

position that was like fitting certain needs,

12:28

but then as long as it met a certain number you

12:30

were like, cool, I can pay off my loans as well as

12:32

like put food on the table. You also

12:34

then became a contractor with the Navy

12:36

as well as you then

12:39

had another employment position with an MSO.

12:42

Did You continue to

12:44

take positions with the,

12:47

with those requirements in place,

12:49

or did your requirements change as

12:51

you went on to those other positions?

12:54

Overall, I, the requirement that really changed

12:56

was, honestly, just a circumstance

12:58

and I'll kind of I'll explain. So,

13:01

the job I came back for was an academic

13:03

position, which was great, but then it

13:05

just didn't work out. That's just the bottom line, right?

13:08

So I, but I signed

13:10

a non compete is a two year

13:13

non compete. And because I'm

13:15

in Virginia Beach, There's only really,

13:17

there's not four directions to go. There's only three,

13:20

right? So, so, at that

13:22

point I was like, well, I can either move my whole family,

13:25

or I could also start,

13:27

looking at the military as a way. And

13:29

Virginia beach or the Hampton Roads area is a big

13:31

Naval town. I don't know if you're, if you're, if you're

13:34

military but they, they have,

13:36

some military opportunities and I just

13:38

happened to apply for it. So that's

13:41

that was definitely actually just

13:43

great luck. Because that's actually

13:46

when I, when I, as I was exiting

13:48

the, the, the second

13:51

job and about to go into the,

13:53

the contractor position, That's

13:55

actually start when I started to think about like,

13:58

how else does this model work?

14:00

And is this model for me? Like, that's really

14:02

kind of where things really kind of started for me. But

14:05

then once I actually got into the,

14:08

the position in the military, it was great. It was

14:10

a sports medicine physician. Is

14:12

it interesting? If anyone's interested in these kinds

14:14

of positions, it was, it was, it was great in the sense

14:16

that all my patients were like, 20

14:19

years old, knee pain, shoulder pain.

14:21

I had an ultrasound machine. The

14:23

trick was that I worked four days a week,

14:26

which was great. But my, I work from

14:28

5am to 3pm. So

14:31

in a sense, it was good because like, I would be

14:33

home for the kids and stuff like that. But

14:35

you know, you're also I'm at work at 5am, which

14:38

meant I was leaving at like 415. But

14:40

it's, I really, I

14:42

really, really enjoyed it. So I don't

14:44

think my, my focus had really

14:46

changed. If anything, I got a

14:48

little bit more focused because during that

14:51

time period, it was really kind of like, I wasn't

14:53

sure if I was going to stay as a contractor.

14:55

Once I actually started to like, you know what, I really like

14:57

this. Versus should I branch

15:00

back out? There's definitely pros and cons

15:02

in the military system, like, like anything

15:04

else. But I think it was

15:06

actually a very important part of my,

15:08

my story of how I ended up where I am now.

15:11

hearing about your non compete that you had with your

15:13

former employer was there any issue

15:15

with you practicing wherever you wanted to

15:18

because you had a contractor

15:20

agreement?

15:21

Then, one of the stipulations was that,

15:24

like, they could, that

16:08

the non compete didn't apply, but it was working

16:11

for the government, so that, that,

16:13

that was real, and in this area, that's,

16:15

that, that's, that's the role, the, the way

16:17

out, and it's, it's, it's funny slash

16:19

sad, I guess, because, like, I would run into people,

16:22

at the, at the, at the military

16:24

facilities of, of other docs

16:27

that were practicing out, and I'm like, oh, it's, it's

16:29

almost like, I don't want to say it's like

16:31

jail, but it's kind of like, Oh, how long

16:33

are you in for because we all do, we

16:35

all sign non competes, but so

16:37

it was just, it was really like my only out, the only

16:39

other option would be to, write

16:41

it out or move out of the area.

16:43

So.

16:45

It's it, I know that there are listeners

16:47

out there who are nodding their heads. I, one thing

16:49

to think about is if, especially if you're new

16:51

to the podcast content, there are doctors

16:54

in all sorts of states who've talked about non competes

16:56

and how to handle them. There's also states like

16:58

California where non competes are unenforceable.

17:01

I hope that becomes nationwide because it's

17:03

ridiculous that because someone says you can't

17:05

practice here. There goes your doctor.

17:07

Like, there goes the expertise out of the area.

17:09

So, definitely something to consider, especially

17:12

if you're earlier on in your journey. If you're

17:14

looking to work with an employer, take

17:16

that, take that clause out if you're able to. Or,

17:20

make the decision based on whether someone

17:22

can take the non compete out or not. So

17:25

let me ask you there because you were

17:27

hearing again, this like, Oh my

17:29

gosh, there's so many things I can do in physiatry.

17:32

And then going to an academic position,

17:34

you had another position, you went to, to be

17:36

a contractor. Did you find

17:38

at all, like, towards the tail end of your contracting

17:41

journey that you're like, but I

17:43

want to do more? Like, did that, did,

17:45

did the the, avatar

17:47

patient that you just, that you just described,

17:50

was that not enough for you? Did that have any

17:53

play in why you moved on from being a contractor?

17:56

Definitely. So, while it was

17:59

great, I was doing a lot of musculoskeletal

18:01

stuff. I wasn't able to do,

18:03

I wasn't doing any injections for the spine

18:05

anymore, and I wasn't doing EMGs.

18:08

And I had actually tried to make

18:10

it work out in the military, because in the military, they're like,

18:13

you can do it. Absolutely. Go for it. But,

18:15

logistically, like, it would

18:18

be too, I would be, not completing

18:20

my primary job in order to fill these

18:22

other holes. So, I,

18:24

at that point, I had stopped doing

18:28

spine injections and EMGs for almost

18:31

two and a half years. And Being

18:33

as young as I was, it was like, I didn't want to lose those

18:35

skills aside from just, I liked

18:37

them, so that's when I was, I tried to make

18:39

it work, but it, it, it, again,

18:41

it wasn't going to work. So that's when I was

18:43

like, you know what, maybe I need to go branch back

18:45

out and try and do this again. But

18:48

I'll, I'll mention, it was also during this

18:50

time that I started looking

18:52

at telemedicine. So,

18:55

one of the, one of the, I

18:57

guess the, my non compete never mentioned

18:59

anything about telemedicine. So,

19:02

and this is like prior pre COVID, so

19:04

I was like, this is, that's actually how I started

19:06

learning about DPC was like,

19:10

can I do this, but I'm, it's, I think it's, it's

19:12

telemedicine back then was like,

19:14

people were doing it, but I don't think it was like

19:16

their primary mode of practice, at least not,

19:18

not to my knowledge, so I, went

19:20

on the Facebook groups and, I look back

19:22

at my old posts from back then, so

19:24

it's kind of funny, me asking all these questions,

19:27

like, does, Does the non compete apply if you're

19:29

online? And it's, and so I met with lawyers,

19:31

I did all this, and everything, it all came down to,

19:34

I don't know, that's a good question, and it's just very, very

19:36

gray, like, so, I started

19:39

to kind of approach that, but as

19:41

an orthopedist, someone who supports medicine,

19:43

it was like, even more like, How

19:45

does that even work? Right? So

19:48

I what I ended up doing

19:50

was my plan was to

19:52

to start off as a telemedicine practice

19:55

just to kind of dip my toe in the water and

19:57

see how it would build. And it was a cash

19:59

based model. So, at that time, insurance

20:01

wasn't paying for, telemedicine visits.

20:04

So, working you

20:06

know, from 5am to 3pm,

20:09

it gave me some time to like to

20:11

try and figure out this model and do all the homework.

20:14

So, I was hoping that okay, I got plan

20:16

A is I just stay with the military plan

20:19

B is that I build up this this telemedicine

20:21

practice and if I decide to go out

20:24

Then I, I could use that telemedicine

20:27

business to funnel a brick and mortar practice.

20:30

So, I, I created

20:32

a model, I had the EMR, I had all

20:34

everything set up. I had some patients coming

20:36

through. And then I had

20:40

taught a couple of people. I was just pitching the idea

20:42

just to say, Hey, what do you think about this idea?

20:45

And so many people just said, wow, this is a really,

20:47

this is a really bad idea. Like to, to put

20:49

it lightly, like that makes no sense.

20:51

Like, how can you treat people? Without

20:54

actually seeing them and I understand

20:56

their point, but at the same

20:58

time, like, I was like, I'm trying to be innovative.

21:01

So I was just about to make the jump and

21:03

then COVID happened,

21:06

right? And so I,

21:08

in my, so

21:11

many people call me, they're like, Oh my God, you,

21:13

you did it, right? You, you hit the jackpot,

21:15

like, and I just laughed. I

21:17

just kind of was like, wow. It's

21:20

like in one move, it completely tanked my model

21:22

because the two things that ever had to happen.

21:24

Number one is that insurance

21:26

would now start to take or pay for telemedicine

21:29

visits and number two, there

21:32

would be no access to in person visits. The

21:35

two things that had to happen, happened and I was like,

21:37

Oh my gosh. So then I got a flood

21:39

of calls, people like, Hey, do

21:41

you, wanting to see me telemedicine wise?

21:44

And they're like, the first question is, do they take

21:46

to do I take insurance.

21:48

And so now they're like, why don't you take

21:51

insurance? So I'm just like, Oh God.

21:53

And so everyone was like,

21:55

well, maybe you can start to recredential. Because

21:57

at the time when I was in the military, all my contracts had

21:59

lapsed. So I was like, maybe

22:01

I could recredential and. Again,

22:04

COVID, like people were not working. So the processing

22:06

time was forever. And I was just like, I'm

22:09

done. I'm done. Like, I can't, it's, it's over.

22:11

I just laughed it, laughed it off. And, but

22:13

it, it actually gave me the opportunity

22:16

to, to build an LLC. So,

22:19

it, it was, it was a good, good opportunity

22:21

from a, from a business owner standpoint. So.

22:23

Let me ask you there, just stepping back into the

22:25

telemedicine experience that you crafted.

22:28

You're talking about how you, you had the EMR,

22:30

you had everything crafted, people were coming in. I

22:33

want to ask about, what what types

22:35

of patients were coming to the practice

22:38

and what were you doing to prove

22:40

all those naysayers wrong with what you had built?

22:43

Right. So, a lot

22:45

of them were, were people that

22:47

I think actually the patients were looking for

22:50

something different, that was number one. A

22:52

lot of the people that I saw were, were

22:54

actually Already doing

22:56

all the conservative management stuff, meaning

22:59

like they, I would get referrals

23:01

from people who just completed physical therapy

23:03

or had done everything and a

23:05

lot, a lot of the, the

23:07

people also just wanted someone to put the

23:09

pieces together. I think that that's what,

23:11

that's actually my, my main strength

23:14

is that as you, as Someone goes to

23:16

with an orthopedic or neurological problem,

23:19

they get an MRI, they'll get an orthopedic

23:21

surgeon consult, they're going to neurosurgeons consult,

23:23

they'll get a million injections. And

23:25

at the end of the day, there's no one to really put the pieces

23:27

back together. So a

23:29

lot of my patients at that time were kind of of

23:31

that mindset, like I wasn't seeing like an ankle

23:33

spring, I was seeing

23:35

people that had like, You

23:37

know what? I've had back and leg pain for this long. I've

23:39

seen, this many people. What do you

23:42

think? So it was, it was more

23:44

of like a consult people wanting

23:46

a second opinion more than, people

23:48

wanting like acute care. Like, obviously

23:50

I'm not treating, I wasn't treating fractures and things like

23:52

that. But it was, that's

23:55

when I really started to realize that, patients

23:57

were really not really happy

24:00

with, What was available and

24:02

they really just wanted someone to put things

24:04

back together in terms of like

24:07

I mean I would literally have to have patients come to

24:09

me and say like I've had all these

24:11

things done and I don't I don't know What happened

24:13

like? And I just need you to

24:15

just explain what this all means.

24:18

And with telemedicine and

24:20

my model, I was like, I had all the time to do it, and

24:22

I really enjoyed that piece of it, so,

24:25

I think that's kind of like what, what really

24:27

drove that piece.

24:28

When you had this telemedicine practice set

24:30

up, did you offer one off consults

24:32

as well as memberships or did you have mostly

24:35

one off cash pay consults?

24:37

It was really just, it was mainly just

24:39

one off type visits. And I'm

24:41

still, even back then, it's, it's,

24:44

it's interesting because like, I

24:46

was playing around with the membership model back then,

24:48

because at the time, there was no, there was

24:50

no PMNR model. Number two,

24:53

all of the direct care models were

24:55

TPCs, which is, a large majority

24:58

of membership bases. Like, how do I, how

25:00

do I do this as a membership? And, and again, as

25:02

Someone dealing with like an

25:04

acute meniscus tear, the,

25:07

I'm not gonna see them forever, you know So it's like

25:10

it doesn't make sense to see them chronically

25:13

Or month and charge them a monthly fee.

25:15

So it's like how is that gonna work? But

25:18

then there are some people that have you know, chronic

25:20

osteoarthritis, rheumatoid arthritis, they

25:22

have chronic issues It's like maybe it's that population

25:26

So then I was like, I'm a sports

25:28

medicine doc and it's like, should I, who

25:30

should I be marketing to? So it turns

25:32

out that I, I'm still right

25:35

now, I'm doing kind of a, a

25:37

one off visit kind of a, still kind

25:39

of a fee for service type of model. But

25:42

I'm still playing around with it at the same

25:44

time. I'm, I'm trying to see what the market actually.

25:47

Kind of wants but but

25:49

I'm open to it. I, I, the,

25:52

I guess maybe I'll share this one thing. One, one

25:54

way that I have seen that

25:56

I kind of played around with is

25:59

if you're going to have a membership model, aside

26:02

from just the, having the, the, the access,

26:05

I, as a specialist, you have to be

26:07

able to offer something, a lot of, I think a lot of

26:09

people in my space are doing. Regenerative

26:11

medicine wellness

26:14

they're offering something extra. And

26:16

while I do injections and I do procedures,

26:19

it's really very, it's

26:21

kind of against my general style.

26:23

I don't like to do injections over

26:25

and over and over. That's not how I believe

26:28

people get better. So

26:30

I was like, well, in this model, I have to give injections

26:32

because I have to give them something, and

26:34

so I was like, well, maybe I could get into like, the

26:36

wellness space or the functional medicine space,

26:39

but I was like, I'm, I'm

26:41

not, I'm kind of like kind of forcing it, in

26:43

a way of trying to like, what else can I add

26:45

to make it worthwhile? And, I,

26:48

I'm not really quite yet sure what direction

26:50

I'm going to go. I'm pretty happy right now with the way

26:52

that it is going in terms of just like a

26:54

straight fee for service, but but

26:56

I'm open to it. I'm still, again, this is now

26:58

that I have time, I'm playing around with all these different ways

27:01

of how to deliver care.

27:03

Amazing. And as it should be, right? Because

27:05

you're thinking about how can I deliver

27:08

care to my patients, not what is the

27:10

next code that will be covering my services.

27:12

So love it. Love it. Now

27:15

one more question on the telemedicine

27:17

portion because when

27:19

you talk about, having the time even

27:21

when you were in your contracting position to

27:24

like Find information on your patients

27:26

to give them an amazing consult.

27:29

That's a big challenge in DPC,

27:31

direct specialty care. When you're independent

27:34

and the local hospital,

27:36

EMR, medical records department won't

27:38

pay, won't play friendly with you. Do

27:40

you have any tips and tricks on getting information

27:43

so that you can have, a very deep dive

27:46

into a person's physical health

27:48

before they come and see you.

27:49

At least in my area, I rarely

27:53

went into the Epic care link. I

27:55

try to get community access as much as possible.

27:57

Cause as we all know, like, notes

27:59

and imaging studies, they somehow find in

28:02

their way into into other charts. So,

28:04

I got access to all the local imaging

28:07

centers as well. And, Virginia Beach

28:09

is a big city, but it's small enough that there's only really

28:11

like three or four places to check. So

28:14

like I have access to the local hospitals,

28:16

but then also some of the local universities,

28:18

UVA, VCU, ECU,

28:20

Duke University, even Mayo.

28:23

I have access there. And for,

28:25

for the most part, that's, that's really

28:27

where I get a lot of my information. Now. In

28:30

terms of, like, talking

28:32

with actual practices, it, it

28:34

is very, very difficult, I'm

28:36

sure, as you, as you can imagine, and right

28:39

now, I'm, I'm, I'm, well, I am and will

28:41

be a micropractice, and my, my wife

28:43

is the one that's helping with all the

28:45

back end stuff, and she's not from,

28:48

she's not from the healthcare background,

28:50

so. It's very interesting. She's

28:52

more from the business business world. And she's

28:54

just like, this all doesn't make any sense.

28:56

Like, we just had a, I just had a a

28:58

patient that are referred to a specialist

29:00

and the fax machine we

29:03

You know, we, we faxed a

29:05

request and did, did, did

29:07

they get it? Did the fax machine at paper,

29:10

it's that whole thing. So I guess the last

29:12

thing I can say is that I think you really

29:14

just have to have a dedicated person

29:16

diligent. And fortunately for

29:18

my model, it's, it's a relatively small

29:20

practice, which is the way that I want it that

29:22

I think that following up on that stuff

29:24

isn't, isn't too onerous.

29:26

I'm sure there's people just like shaking

29:28

their heads at what you're saying. I

29:30

know that I have this conversation frequently

29:33

about how patients, when they go

29:35

to a fee for service clinic, they're like, I can't

29:37

access my chart. It's so not helpful. And I'm like

29:40

and then, I absolutely get the whole

29:42

like, well, we never got the chart. the imaging

29:44

that you sent over that you claim you faxed over.

29:46

And then so now we save

29:49

our documents and our faxes that we

29:51

send to the patient's chart where they can literally

29:53

pull it up and print it out. So we've

29:55

had less barriers to also get our patients

29:58

their studies that they need for their specialty visits

30:00

because they can pull them up on their phones. And

30:03

I love, the descriptions of like, Yeah,

30:06

the doctor was like trying to skirt past

30:08

it. And I was like, do you mean this calcium

30:10

score right here on my phone that you can see? I

30:12

love it. I'm like, yes, go patients.

30:14

Yay. So yeah, love it. Now

30:17

tell me about your transition from

30:20

your your opening your own LLC,

30:22

having a telemedicine having a telemedicine

30:24

practice, and then going into

30:27

an MSO after that. So, what

30:29

was the, I know you mentioned

30:31

COVID, was that the main driver to

30:34

that led to the MSO?

30:35

you know, yes And no. I mean, if anything

30:38

there was there was some safety in staying

30:40

in the military. Because it

30:42

was a contract. It was a contract. So

30:44

it's like guaranteed pay and so on and so

30:46

forth. But I

30:48

just knew that I was like, well, I, I haven't

30:51

really established myself in this area,

30:53

meaning like I got into this area in 2016.

30:56

I practiced for two years at an academic center

30:59

and then disappeared for another two years. So

31:01

it's like, people, just talking with

31:03

people like, where do you work? And if you're in the military,

31:06

you can't be really seen by anybody, they're like, oh, you're

31:08

a doctor. Can I see you? I'm like, well, are you active

31:10

duty? Like, no. Okay, you know, so it

31:12

was always this, awkward conversation.

31:14

So, but I, I really wanted

31:16

to kind of see medicine

31:19

the way that I wanted it to be done. And

31:21

even when in my very first

31:23

job, I was like, I always had these

31:25

ideas of how rehab and

31:28

it should work. So it's like, okay,

31:30

this is an opportunity where I can

31:32

actually do something in

31:34

person, with every, it's basically

31:36

I can control everything. And

31:39

I just wanted to see how it would go. And

31:42

it was, from a practice standpoint,

31:44

it was, I was full, I'm,

31:47

I had all the types of patients

31:49

that I wanted to see. But

31:52

at the same time, like an insurance based model,

31:54

like I found myself just not

31:56

being able to spend enough time with the patients. And

31:59

I, I fortunately never let

32:02

myself head into like that

32:04

30 to 40 patient range, but I,

32:06

even still I was still seeing people like 20

32:09

to 20 to 25, which is still a lot.

32:12

And, I, I just started to

32:14

re you know, notice that I was like, you know what, you're

32:16

just not, I just wasn't happy. I mean,

32:18

just, just flat out, like at the end of the day.

32:20

And I think it was actually

32:22

burning out and, and I didn't realize

32:24

it. And, or I was burning out and

32:27

I didn't realize it. And so

32:30

the thing that really kind of like triggered me was

32:32

that like, there was just like

32:35

the billing, like I was doing all this hard

32:37

work and the, the money wasn't coming back.

32:39

And just the philosophy of like, well. We'll

32:41

just write it off and we'll go for the next one. It

32:43

just, just didn't make sense to me. And

32:45

I was like, this, why am I working so hard

32:48

to maybe get money, or the

32:50

fact that like the billing claims

32:53

ring managed by people who were not motivated,

32:55

there was no incentive for them. So

32:58

it really kind of like, got

33:00

me thinking like, is this what it is? This

33:02

is, this is what my life is. And I

33:05

had this like, Long time

33:07

ago, I set this timer on my,

33:09

on my phone of when

33:11

am I going to like retire? You know, Again,

33:13

I wasn't, I'm not super financially literate, but

33:15

at the same time, I was also thinking of that, like

33:18

the fire movement, like retiring early, things

33:20

like that. So I'd set a date

33:22

for my son's 18th, when he

33:24

graduates high school, basically. And I was like,

33:26

that's, that's the date that I'm going to just, I'm going to cut

33:28

back. It's, it's a financial goal. It's a life

33:31

goal. So on and so forth. But then. I

33:33

found myself looking at that clock more

33:36

like every day. I remember looking at

33:38

the, at, at, at that timer

33:40

and then going to work. And then I

33:42

was like, man, this is not,

33:45

this is not good. And it

33:47

just, I brought up concerns and

33:49

I just knew that the, it wasn't going to work

33:51

anymore. And I.

33:54

I essentially kind

33:56

of, I'll, I'll call it. I just kind of quit.

33:59

Just, I just quit at

34:01

the end of the day. I was, I remember I was

34:03

on I was on a cruise with my family. I was on vacation

34:07

and I was like

34:09

looking through the, my phones,

34:11

I was just kind of looking over at the sea and just like,

34:13

at the ocean, just looking at my phone and my, the

34:15

pictures over

35:20

the years, and

35:22

I just noticed that my face, like I

35:24

was, I stopped smiling. Like I

35:26

just saw myself change and then like.

35:29

My, my daughter actually,

35:31

she's, she's, she's probably at the time

35:33

she was like maybe 11 or 12, she

35:35

said, or she was 12 and

35:37

she was just like asking me, are you okay?

35:40

Like, everyone's always like, what's wrong? I'm like, nothing's

35:42

wrong. And, but apparently like every battle, everybody

35:44

else could see it except for me. And

35:47

then. I was literally on the boat

35:49

looking over and I just was like, I'm

35:51

done. I can't do this because I

35:53

was, I was like, it's either I quit medicine

35:55

or, or I find a different job

35:58

to do something because it was like, I'm just not doing what I want

36:00

to do anymore.

36:02

Like you talk about your non compete, it's like, that's

36:04

an even worse non compete, equivalent.

36:06

It's like there, you only have two options. So,

36:09

in leaving medicine sucks

36:11

for all of us who have gone to medical school and

36:14

have invested our, mostly our twenties in,

36:16

sorry, we can't go to your wedding. Sorry, we can't go to your

36:18

Christmas party. I need to study

36:20

for my board exams. So I'm so glad

36:22

you did not quit medicine. Because

36:25

you already had your LLC, because

36:27

you had already, dipped your toes into

36:29

a cash based practice, what

36:32

was the transition period like between

36:34

opening up your practice as it

36:36

stands now and your former job?

36:40

So two months, so,

36:43

I literally, as soon as I came back

36:46

from vacation, I just, I just said, I'm done.

36:48

Here's my two months. And this is the date.

36:51

So my last official day was

36:53

October 31st of 2023.

36:56

And I opened up November 1st. But

36:59

I, I think I was just mentally

37:01

ready. I actually have this like, kind of this,

37:04

like this kind of idea journal.

37:06

And I started going, from when I

37:08

created the telemedicine business and I started,

37:10

I date everything and I write everything and, every crazy

37:13

idea that I have, I write it down. And

37:15

I went back to 2016.

37:18

And so I had, I had to actually

37:20

have these ideas for a long time. And. I

37:23

kept rewriting the same idea over and

37:25

over and over 2017, 2018.

37:27

I just never looked at it, in totality. Right.

37:30

And so I was like, bro, you've been

37:32

wanting to do this for a long time. So, I

37:34

was just like, so once I saw that, I was like, I'm

37:36

ready. I know I'm ready. So I just need to find

37:38

a place and, This and that, like

37:41

I had already thought about everything else. I mean, of course

37:43

there's like, EMR and things like that. I

37:45

had to work out, but just logistically I was like,

37:48

I, I think two, two months

37:50

is a really short time for someone that's never thought

37:52

about it. But at the same time,

37:55

like I had thought about it for such

37:57

a long time that it wasn't, it wasn't that scary for

37:59

me, but I know for a lot of the listeners,

38:02

that still sounds kind of crazy, even if you gave yourself

38:04

a mental deadline of like, I'm going to do it in five

38:06

years. I think that it's, it's, it's

38:08

kind of a hard pill to swallow, but I

38:10

tell you, the, the one thing, and maybe

38:13

for the listeners, the one thing that really kind of made

38:15

it happen is like, I had to find ways to

38:17

make it real for myself. And

38:19

the one thing that I did was I bought a website

38:22

with my name on it, and that's when

38:24

I was like, all right, man, you're going to do it.

38:26

I was like, you bought it, you bought it. So like, we

38:28

got to do it. Plus I'd put in my notice. So

38:30

I was like, well, like you

38:32

gotta, you gotta get back to work. So, but

38:35

two months, short answer, two months.

38:38

Super powerful. And, I that's

38:40

definitely something that physicians have used

38:42

in different specialties in terms of the transition

38:45

to another practice of their own,

38:48

whether there's a non compete or not having a blog

38:50

that is your own and that transitions

38:52

later on to your website.

38:55

Dr. Emily Scott is a great example of that. you

38:57

have Dr. Fred Beguiris Dr. Haley Miller

38:59

had her website just featuring her as

39:01

a doctor. So she was an individual, not

39:03

part of the system anymore before opening Montana

39:05

State Diabetes. So I absolutely

39:07

love this and I think it's a great gem for

39:09

people to take to think about when,

39:12

when you're not yet ready, but you're

39:14

like, I'm ready, but I'm just not ready

39:16

to pull that trigger yet. You can absolutely

39:18

do things like this that empower you. And like

39:20

you said, like, you're motivating

39:23

yourself to make this thing real, because

39:25

this is not a magical unicorn type of practice.

39:28

This is legit, like you're a physiatrist doing this.

39:30

So love that. Now, let me ask

39:32

you, because you had done again,

39:34

this, like dipping your toes into cash based

39:36

practice. And then you're like, this is like, for sure,

39:39

this is what I'm doing. In

39:41

the state of Virginia, there's quite a few DPC

39:43

doctors and specialty doctors as well.

39:46

How did you ask, like, what

39:49

was your mindset in terms of how

39:52

you asked questions about, what,

39:54

what they were doing and how you would incorporate in their,

39:56

how would you incorporate what they're doing

39:59

strategically into your practice or not

40:01

based on, you not only

40:04

having these journal entries from 2016,

40:06

just like thinking about this over and over, but actively

40:08

like shifting your mindset to, no,

40:11

I'm doing things to make this real.

40:13

That's, that's a good question. I mean, I think overall,

40:16

like I talked to the couple of the, the drug

40:18

primary care docs in the area and just

40:20

trying to figure out like, what

40:23

do their patients, what does, what

40:25

do their practice needs and like, is

40:27

there a space that I can fill for them in particular?

40:29

And. I I

40:31

don't know if I really got the the answer that

40:34

I was I was hoping for in the sense of

40:36

like Oh, this is what I can do Because

40:39

especially as a specialist I I think

40:42

one of the main challenges is that most people

40:44

will look at me and say like well

40:46

I need an injection for my knee like I can

40:49

go and get that or from

40:51

my you know insurance my in network physician

40:54

And I had to really

40:57

change my mind in terms of saying like,

40:59

you know what? They're trying to equate

41:01

me to that. And I was like, I'm not

41:03

that. So then I started

41:05

to have the question of like, okay, well what,

41:07

well, what are you, right? Like, like what

41:09

is your practice? Like, who are,

41:11

what, what can you offer? And

41:14

so I, I, to answer your question, I think the

41:16

mindset is really, I mean, it, I hate it

41:18

to not to get too, philosophically you really have

41:20

to understand like who you are and what you

41:22

stand for and what it is that you wanna do. And

41:25

I think I was, I, I, I'm a huge fan

41:27

of DPC docs, and I've always like

41:29

kind of wanted to talk to them about, what

41:31

was their motivation. And, even

41:34

though the motivation is the same, I was like, I still

41:36

don't really know what it is that makes

41:38

me different or makes me special. I

41:41

mean, at the end of the day, I think that, it's

41:43

me, I'm, I'm the product, I, yeah,

41:45

sure, I give injections, but, and sure, I,

41:48

I figure things out, but I'm,

41:50

I'm the product. And I think

41:52

trying to, to. change

41:55

the mindset of how to

41:57

for you to appreciate how valuable you are

42:00

to the community and what you can offer patients.

42:03

Like I couldn't have read that in a book, I might

42:05

have heard that someone say something that might have resonated

42:07

with me. But I mean, there's been so many times

42:10

over the past, four months that I've been open that I'm

42:12

like, rough days, man. I

42:14

was like, why are you doing this? And

42:16

I've had, I've had offers to do, to

42:18

do other things, to come back and

42:20

to this and do that. And, but

42:22

I'm just like, I think I just had to,

42:25

just really value yourself as a physician,

42:27

as a person in general, it's

42:29

like, I think it's just something that we don't ever really

42:31

have to stop and do and. I

42:33

think when you're trying to market yourself and

42:36

sell your practice, that's a hundred

42:38

percent what you have to do is like, you have to value yourself

42:40

because you'll get low balled. You'll get this and

42:42

you'll get that. And I'm just like,

42:44

Nope, sorry. It's not a good fit. And

42:46

I just kind of move on. So I

42:48

think really just valuing myself is

42:51

to answer your question was the mindset shift.

42:53

So, pause, rewind that about

42:55

15 seconds and replay that over

42:57

and over and over again. Because absolutely,

43:00

I mean, it is, it is a vital

43:02

part of what we are doing in direct

43:04

primary care and how we preserve our autonomy

43:07

and how we write our copy on our website

43:09

and how we speak to people about what we're doing.

43:11

When you know that you are valuable, even

43:14

though the former employer said, we're going

43:16

to a non physician model. Or,

43:18

I'm so sorry, like, you're going to have to see 80

43:21

million patients per hour so

43:23

that you can make the same codes because we're paying you less

43:25

per code. Whatever it is that makes

43:28

one feel devalued as a physician in

43:30

the, regular fee for service system, stop,

43:33

rewind now 20 seconds and

43:35

listen Bagheera again, because

43:37

that is so imperative for what we are doing

43:39

and to be able to thrive in this movement. Absolutely.

43:42

So, love it. Absolutely. Love it. Let

43:44

me ask you then because you, we're

43:47

saying like done. I'm doing it. I

43:49

am actively doing it. I have my brick and mortar. I

43:51

want to ask about the challenges and

43:53

opportunities being a physiatrist

43:56

with a space because I hear

43:58

people and I know you have as well

44:00

of like, Oh, I can't afford an

44:02

ultrasound to start off with or like, I

44:05

and you talked about the marketing piece and like who

44:07

was joining your telemedicine practice, but in

44:09

terms of as you continued

44:12

on and had the space

44:14

to then build out to make it fit

44:16

what you wanted to bring to your community, how

44:18

did that manifest in challenges and opportunities

44:21

specifically with physiatry care and

44:23

orthopedic health services?

44:26

So you know, fortunately

44:28

for me, I, the, I

44:31

had three main pieces of

44:33

equipment that I use. So an EMG machine,

44:36

an ultrasound machine and

44:38

a fluoroscope and

44:40

the fluoroscope I'd never owned, but I did

44:42

own the EMG and the, and the ultrasound.

44:44

So as I was exiting,

44:47

I just had to obviously make, I had to pay off the

44:49

difference. And, and, and then it,

44:51

because it was purchased through my, my

44:53

previous employer and I just purchased it

44:55

from them. So I just

44:58

knew I had to have that. But then it came

45:00

up to like, well. to do at

45:02

to do injections of the spine,

45:04

do I want to buy a new machine? And aside

45:07

from the cost, the build out, these things can

45:09

be like between 80, 80 to 100, 000.

45:12

And I was like, I'm going to need an extra room, to

45:14

do that as well. And then I'm going to need

45:17

extra staff. And it just, it gets bigger

45:19

and bigger and bigger. So

45:21

right now, I, I did

45:23

find a place, I'm some renting space out

45:25

of a an internal medicine, doctor's

45:28

office, I have one room. With

45:30

both machines but I'm not doing injections

45:33

for the spine anymore right now. So,

45:35

I, I was previously doing it at a surgery

45:38

center and that's still a potential option

45:40

kind of given the right payer. Like, I, while I don't

45:42

participate with, with commercial insurances

45:44

and I opted out of Medicare, I, I still see

45:47

workers comp patients. So, that,

45:50

that might be an avenue, but at the same

45:52

time, like, I, again, I,

45:54

I think I really just kind of came down

45:56

to what my, I feel

45:58

my role is. is to

46:00

to help people put pieces together like

46:03

the injections were great, but I realized

46:05

that it's not some it's not it's not the biggest

46:07

thing, in my opinion, like it's really

46:10

interpreting the injection being there for patients,

46:12

making them

46:56

feel you know, that they have some control

46:58

over what what has actually happened. So, in

47:01

terms of like the challenges, it's,

47:03

like, I have all the stuff, I have a room,

47:05

I have, I have all the equipment, nothing's really been challenging

47:07

from that standpoint. Fortunately, the equipment

47:10

that I did purchase wasn't super expensive

47:12

but again, I had already kind of planned for it.

47:14

So if anything, I just, made

47:17

sure that when I paid off, I could get, I, I

47:19

could do, use, use a credit card to get points

47:21

because I love points, points, points throughout my travel.

47:23

So that was, that was kind of how

47:25

I just figured out that piece. And then I just kind of paid it off,

47:28

like, just like a here and there, but But

47:30

I'm, I'm not really looking to expand

47:32

just yet or if ever, because it's just

47:34

a room, most of my visits like yours are like,

47:37

60 to 90 minutes. I was like, well, I don't need

47:39

two or three rooms anymore to go run, from room to

47:41

room. But yeah, I

47:43

think that that's, that's pretty much it.

47:46

Fantastic. And let me ask you about the

47:48

using the space in the internal medicine, internal

47:50

medicine physician's office. Was that like,

47:53

Hey, I'm asking around for people

47:55

are asking around if people have space.

47:57

Was that like a, Facebook marketplace

48:00

listing like Jenna Silikowski and her

48:02

buying her DPC off Facebook? How did

48:04

that manifest?

48:05

So, It my, my,

48:08

the person I'm renting space from

48:10

was actually my physician was my own personal,

48:13

like, internal medicine doc, and they,

48:15

they are solar practice, but

48:17

they're also still in the commercial

48:20

space too. So I was just like, Hey, if you,

48:22

basically if you hear, I just. if

48:24

you get, do you have any space basically, everyone that I

48:26

knew. And so I just

48:28

said, Hey, do you have a spot? And he was like, sure. And this place

48:31

happened, this place is also right down the street from my

48:33

house. So, yeah, that's, that's pretty

48:35

much how I did it. It was like, I went, I didn't

48:37

really look like online or anything

48:39

like that. I just kind of called everyone that I knew and just

48:41

said, Do you have space? And and everyone

48:43

has like, and like, I needed one room, so

48:45

it wasn't too big of an ask. So.

48:48

That's great. And in terms of the agreement,

48:51

are you like, was that an

48:53

easy negotiation? Do you have a particular

48:55

year lease? Are you just paying by the hour? How

48:57

do you, how do you, how's that agreement working?

48:59

Right.

49:00

Right now I'm going month to month so

49:02

it's it's working out so far, the,

49:05

the doc that I'm renting it from was, more

49:07

than happy because he was, he wasn't

49:09

even using the room. So, I'm

49:11

hoping it, so far so good. It seems to be

49:13

working out. Like, I don't really think

49:15

I need, I'm not in a rush to move at this

49:17

point. So.

49:19

And this question is coming from, like, I,

49:22

I, I'm just assuming that there's a shared

49:24

entrance space for patients of

49:26

the practice your practice, as well as this internal

49:29

medicine physicians. Yeah. Yeah.

49:32

Go ahead.

49:33

Yeah. No, it's the space actually works

49:35

out because it is a medical building. So

49:38

on the same floor is a

49:40

physical therapy clinic and an orthopedic

49:42

surgeon and primary

49:45

care as well. But

49:47

so it's, from traffic

49:49

wise, it's good, people picking up stuff

49:51

and seeing, seeing my practice my signs

49:53

and everything like that. It seems to be working out.

49:56

I'm laughing because I, I assume that this has

49:58

happened and I hope it has, but the person

50:00

who's sitting there, patients in my old practice,

50:02

like an hour and a half, and they're like, how come

50:04

Dr. Begaris's patients keep moving

50:06

and moving and moving and I'm still

50:08

sitting here parked in the parking lot, waiting

50:11

room. So I, I, that's why I'm laughing, but,

50:13

oh my goodness, I'm, that's amazing though that

50:15

you do get that, Hey, what,

50:17

what is, what else is in this amazing medical

50:19

building? Awesome. Yeah. Let me ask

50:21

you now about your journey in opting

50:24

out of Medicare because that is a big challenge,

50:26

especially for specialists like Dr. Grace

50:28

Torres. Another fellow Filipino doctor,

50:30

but she talked about how in

50:32

podiatry, most of her patients were going

50:34

to be with a Medicare plan. And she was like, when

50:37

I let them go, I made space for people

50:39

who valued me and who wanted to pay cash for my services.

50:41

So what was your journey like opting

50:43

out of Medicare? And did you ever have any hesitation

50:46

to opt out or not?

50:48

So I did opt out of Medicare

50:50

I started that process about

50:53

like, it's interesting because like,

50:56

I wasn't sure how it would happen. Because

50:58

when I quit, or I put in

51:00

my notice about two months prior to me actually leaving.

51:03

And I was like, maybe I should I should start opting

51:05

out now. But I didn't want to

51:07

like, throw out flags at the same time,

51:09

so, it caused problems like

51:12

towards the end. So I, I actually chose

51:14

about two weeks prior to me leaving. And

51:17

it was kind of, it was fairly simple and it was

51:19

kind of anticlimactic because it's literally just

51:21

a form and I was expecting something, I

51:23

don't know, something bigger. And

51:26

But then, there, I was like, well, when does this

51:28

actually get off, get approved. And so

51:31

it took about two months,

51:34

I think, no, no, no, maybe about six, six

51:36

six to seven weeks before I actually. figured

51:40

it out. And I never got him.

51:42

I never got a letter. I never got anything

51:44

like that. I just went to the website. I'm

51:48

using the opt out tool to figure it out. But

51:51

in terms of the decision, it was easy.

51:53

I was like, I got to burn the boats, and I was like, I'm,

51:56

I just can't do it. Because it's

51:59

just too easy to get sucked back

52:01

in. I mean, even now, like, I I

52:04

do run into some problems a little bit because

52:06

I'm trying to figure out, in terms of

52:08

like working, partnering with other practices

52:10

and offering my services

52:12

as a 1099.

52:15

And still the same issue is that,

52:17

even though I'm 1099, I still have to be somehow

52:20

credentialed through them. And I was like,

52:22

see, I'm glad I didn't do it, because it's

52:25

just gonna, I mean, from obviously

52:27

you want to, you need, you need to see people,

52:30

you need to make money, but. I was like, I'm

52:32

not going to get sucked back in. I, I just

52:34

told myself that I was like, no, I'm done.

52:36

So, so it was, so mentally

52:38

it was very easy for me. I, I didn't, I, I see all

52:40

the posts. I, I, I

52:42

won't be able to do locum's

52:44

work. I think that was a big concern of mine,

52:46

but I I'm done. Like,

52:49

like, I just was like, I don't care. I.

52:51

My two happiest jobs prior to

52:53

being a physician was selling shoes at Foot Locker

52:56

and working at the airport, escorting

52:58

people by wheelchair.

53:01

And I was like, I would much rather do that. I was

53:03

so much happier. So

53:06

I just kind of was like, I'm done. I

53:09

love it. And I'm sure that if people

53:11

stop and think that they would find,

53:13

other jobs, like I used to teach summer camp

53:15

at the Sacramento Zoo. And I'm like, that versus

53:18

asking someone if they wear their seatbelt during a Medicare

53:20

physical wellness visit. No, thank

53:22

you. I would absolutely take, scissors

53:24

and glue sticks in my pockets any day. So love that.

53:27

Now, let me ask, let me ask you this, because this

53:29

is something that I was like, Oh my gosh,

53:31

when we set up your interview I

53:33

had, just doing research for this interview. I

53:36

was like, how is how is that

53:38

that your former employer has

53:40

an announcement about you leaving the

53:42

practice on their page? Like that was something that

53:44

threw me for a loop. So can you tell the

53:46

audience about what what happened?

53:48

What transpired there? And has it affected

53:51

your practice in a good or bad way at all?

53:54

So, yeah, I mean, the big

53:56

thing I noticed, You

53:58

know quickly right after is that the

54:01

the internet google searching your name is

54:03

a big is huge and

54:06

so I wrote a letter to

54:09

just my departure letter to patients and

54:12

prior to me leaving and

54:14

it went out by paper, right? That's just

54:17

kind of just from that standpoint. And

54:19

then I noticed like six weeks later that

54:22

after I'd left the practice that they now

54:24

posted it online and I was like, well,

54:27

why, why post that now? The,

54:30

but what it did do is it actually bumped my,

54:32

my ranking down. So it's not the

54:34

first thing. And so, I

54:36

can only speculate. I'm not sure exactly why they

54:38

did that then on a, because

54:41

I was really pushing for them to do it

54:43

way before I actually left. And

54:46

that was a struggle on a different conversation,

54:48

but so, but it didn't

54:50

really affect, it didn't really affect me

54:52

if, if, At least that I can tell,

54:55

but I, there's

54:57

not really much for me to say about it. I was just

54:59

really kind of confused because I had already

55:01

been gone for six weeks. So why post it

55:03

now? But at the end of the

55:05

day, press is press, my name still pops up

55:08

and my, my, my other two websites

55:10

still pop up. So, it, it's, it

55:12

hasn't really bothered me.

55:13

Now with your practice MSK Direct, I'm

55:16

super excited to start asking these questions about the

55:18

details of your practice because there was a PMNR

55:21

doctor that I had met, who's based out of Vegas.

55:24

I had met him at the Take Medicine Back conference

55:26

early in February, and he was like, I

55:28

could never do DPC. And I'm like, my

55:31

hands are doing What is Mr.

55:33

Mr. Mr. Burns, like, fingers

55:36

when, when people say these things to me, but

55:39

for you when you opened up

55:41

your website, you had your room, you're like, I don't have

55:43

my fluoro today, might be coming

55:45

down in the future. Did your

55:47

services start off with like

55:49

a set number of services? And then

55:51

have you expanded from there? Or

55:54

have you listed everything you do to see

55:56

what sticks?

55:58

Yeah it's right now. It's just a set

56:00

set number of services. And

56:03

for the most part, I, it's really

56:05

the, the patients that have actually been seeing me

56:07

really, they're not really interested in the injections.

56:10

It's really been more of like, I've had

56:12

the injections. I just want to know what's wrong. So

56:15

most of my care, like, again,

56:17

is like, is really just trying

56:20

to be a good doctor and trying to

56:22

figure things out for people. But

56:25

again, it's, I think that people

56:27

are kind of maybe selecting me for that reason

56:29

and I think my website kind of goes in like

56:31

you read my general approach and even on

56:33

my, on my, my Instagram, I have

56:35

a certain style of practice

56:38

and I mean, injections are great procedures are

56:40

great, but. There's no shortage

56:42

of people doing procedures, at

56:44

least in, in, in my specialty,

56:46

it's really, there's a, there's really

56:49

a place for people to help actually putting, put

56:51

things back together and explain what exactly

56:53

what happens because I think.

56:56

A lot of people perceive these procedures

56:58

that we do as like the end all be all,

57:00

but it's, it's not, it's, it's like, what

57:02

does the procedure mean to you?

57:04

What does it allow you to do? Does this,

57:07

does this injection allow you to sleep

57:09

better? Get off of medications?

57:12

Are you, are you going to move more? So

57:14

I haven't really, really pushed

57:17

doing more procedures, because to me, procedures

57:20

aren't, aren't what is missing from

57:22

the, from the community. It's people

57:24

who actually understand rehab and,

57:26

and how pain works and,

57:29

and looking at the natural history of chronic

57:31

musculoskeletal disorders. Like there's

57:33

just, I mean, I'll say it right now. There's no one like me.

57:36

I'm the best. There's just really, I'm, I'm

57:38

just getting, like I said, value yourself. Like I'm telling you

57:40

right now, I'm the best. Come see

57:42

me in Virginia Beach if you want to get figured out, but

57:45

so like I said, the services isn't,

57:47

isn't my, isn't my cell.

57:49

It's me.

57:50

And I think about how, at least

57:52

we were taught at Creighton 80 percent

57:55

of what you need is coming from the history

57:57

and not the, 20 percent

57:59

of physical exam, absolutely. It's going to back

58:01

up what your differential is when you're thinking, but

58:04

this is why going to doctor school matters because

58:06

we've had the training in an hours,

58:09

thousands of hours, more than a non physician

58:11

provider to be able to think. And

58:13

then that is a, that allows us

58:15

to then, especially after you realize

58:17

that you are valuable. Be able to talk with

58:19

your patients with the time you need to be

58:22

able to share exactly what is

58:24

going on in your head, how you came to a decision

58:26

and how to explain that in plain English rather

58:28

than medicalese. So I absolutely love

58:30

that. That's what your value proposition is,

58:33

that that is the value

58:35

proposition that you find your patients are loving. So

58:38

let me ask you here about. Your

58:40

website. When you have your services

58:42

listed and there's a contact form, what

58:45

does it look like after someone says like, Oh,

58:47

I'm totally interested in this practice. I want to learn

58:49

more. Do you have a meet

58:51

and greet phone meet and greet virtual meet and greet? What happens

58:53

after a person says, yes, I'm interested

58:55

on your contact page.

58:57

I'll get an email, and I just call them and

59:00

see and see what they, what it is that they need.

59:02

I've had a lot of patients from

59:04

my former practice, try to follow up with me.

59:06

Some of some continue to follow me. Some,

59:08

some of them had to it, it wasn't a good fit.

59:11

But I I'm a big fan of calling,

59:13

cause again, I, that's where I think

59:16

I shine the most. And, and where I can actually

59:18

really answer questions and sell myself

59:21

when necessary. So, I

59:23

tried to, I'm also trying to eliminate

59:25

the tech. I love tech. I know you

59:27

love tech too, but I'm trying to, to,

59:29

I shouldn't say eliminate the tech, but try to increase

59:31

the human interaction. So,

59:34

I try to call the patients, text them as soon

59:36

as possible. Like I just had a, I

59:38

had a patient the other night, they texted

59:40

me like at eight o'clock at night.

59:43

And I just said, Do you want to talk? And she's

59:45

like, sure. So, I

59:47

just kind of just handle it right then and there. I mean,

59:49

that's just kind of what I know. That's not, that's not the way

59:51

that everybody does it. But like, I

59:54

don't know, it motivates me, like, if like,

59:56

I, as if I was a patient,

59:59

and I just was like, Oh, wow, this guy actually,

1:00:02

I mean, I hate to say this guy actually cares and wants to do,

1:00:04

is really excited to talk to me.

1:00:06

Like, I want my patients to

1:00:08

feel that way.

1:00:10

I love it. And I will quote Dr.

1:00:13

Dr. Amber Beckenhauer, you do you.

1:00:15

This is your practice. You do you, man. So

1:00:18

let me ask you now about the website

1:00:20

and the analytics. When you started,

1:00:22

did you have the video that exists of

1:00:24

you talking about the practice on the website?

1:00:26

Or was that something that you added on later?

1:00:29

That was from the, that was kind of from

1:00:31

the very beginning. And part of that also

1:00:34

was. I had the website

1:00:36

up prior to me actually opening, but

1:00:38

then I just kind of de identified it, so like

1:00:40

I took out my name. There was like, there was another timer.

1:00:43

I guess apparently I'm a big fan of timers. There

1:00:45

was like a countdown timer of,

1:00:47

of this grand, this big reveal kind of a thing.

1:00:50

But doing that video was like, took me like a million

1:00:52

takes and it was like, again, I

1:00:54

have a microphone here. I'm trying to like, what am I trying

1:00:56

to do? Am I trying to like be on camera?

1:00:58

Like, that sort of thing. And, but

1:01:01

it, Again, it's, it's, it was a great

1:01:03

exercise because I was like, I had to really concisely

1:01:05

tell people what it is that I do without,

1:01:08

losing their attention, that sort of thing. But but

1:01:10

yeah, that's my main video. I have some other

1:01:12

things I'm working on and I'm hoping

1:01:14

to kind of build off of that kind of stuff. But

1:01:17

I love it. It's such a transition from

1:01:19

what you shared, early on before your

1:01:21

direct specialty care journey in

1:01:24

working on the business, that's not a thing

1:01:26

that we do when we're employed.

1:01:28

So, now let me ask you here about

1:01:30

the, The places that people most

1:01:33

visit on your website, do you see

1:01:35

that people are visiting a particular

1:01:37

page more so than others? And have

1:01:40

you adjusted your website to, to

1:01:42

speak to that data?

1:01:44

It's the way I have my, my website

1:01:46

set up, it's Basically the landing page

1:01:48

is the main page, so they don't

1:01:50

really have at least analytics

1:01:53

wise. They don't really click past that

1:01:55

too much because everything is on there. And

1:01:58

I like that by design. I'm just, I hate

1:02:00

clicking and I try to avoid clicking. I assume

1:02:02

everyone doesn't like to click. So, I

1:02:04

haven't really noticed any people kind of venture

1:02:07

off too far from the click. I've noticed

1:02:09

a lot of people will just go off a straight

1:02:11

Google, like you Google search and then like

1:02:13

you get that box on the right. So I've definitely

1:02:15

had a lot of people just go straight off of

1:02:17

that to call. I never really understood what

1:02:19

all those hyperlinks were, but now I do. On

1:02:22

the side. So, getting your, getting

1:02:24

your, your Google straight is, is super

1:02:26

important for sure. I, I. I've

1:02:29

always known it was important, but it's,

1:02:31

that's where people look, and that's just, that's just the way

1:02:33

that the, that the game's played. So that'd

1:02:35

be the one advice I have is that if you can, get

1:02:38

your Google business account, grab it for yourself.

1:02:41

That took a while that, that took a long

1:02:43

time because I had all these

1:02:45

great reviews with with my old practice.

1:02:47

And at the time I wasn't sure if they were gonna, release

1:02:50

it back to me. So I

1:02:52

opened up a separate Google, a

1:02:54

separate Google business. And then it turned

1:02:56

out they actually did release it. So now I had two

1:02:59

and then I had to consolidate into one. It

1:03:01

was it was a it was a whole ordeal. But it

1:03:03

you know, it, it took a couple

1:03:05

months to get that thing straightened out. So

1:03:07

it could see it. It, I was, I,

1:03:10

I looked really messy online. Like it showed my old

1:03:12

practice. It said I was permanently closed

1:03:14

and then I had all these other practice, cause I was, it

1:03:16

was a mess, but yeah.

1:03:18

I totally echo that. And that's something

1:03:20

that even if you are employed, you can

1:03:23

still. Claim your Google profile

1:03:25

as like doctor so and so. But

1:03:28

yeah, I'm going to challenge people like if

1:03:30

you are posting this week, anybody on social

1:03:32

media tag my DPC story

1:03:34

and put hashtag stupid

1:03:36

postcard on your post because

1:03:38

that postcard, it was like, that's what drove me

1:03:41

nuts. I mean, I was like, wish that

1:03:43

I had done my Google page earlier, because

1:03:45

at least, I live in rural America. So like,

1:03:47

I don't have a physical mailing address, you

1:03:49

have to mail to P. O. boxes,

1:03:51

and they don't mail to P. O. boxes. So

1:03:53

I was like, well, this is an amazing catch 22.

1:03:56

So thankfully it worked out

1:03:58

that I could, I could send it to somebody who

1:04:00

did give me the postcard from my address

1:04:02

that I sent it to, but it was like, Oh

1:04:04

my gosh, so mad. So yes, like,

1:04:07

I totally agree with you though.

1:04:08

Yeah. Yeah. But I did, I do think

1:04:10

that did help a lot, so it, I

1:04:13

think it's worth, it's worth it, so if

1:04:15

you, if you can, do it ahead, if you can

1:04:17

claim your profile before you leave, that's great.

1:04:20

That's, that's probably your best case scenario, but

1:04:22

you know, it's just. Don't give up on it, especially

1:04:24

if you have good reviews on there. So

1:04:26

how about, because. When you spoke

1:04:28

about your contracting with the Navy

1:04:31

keeping up your set of skills was important

1:04:33

to you. So you've talked about like, could you provide

1:04:35

services to other people? How are you focusing

1:04:37

on making sure that your scope of practice

1:04:40

is still where you want it to be going forward?

1:04:43

I think part of it is actually trying

1:04:45

to, number one, I don't

1:04:48

think I want to be a big practice ever

1:04:50

again. So having a single

1:04:52

room is very intentional. I

1:04:54

think if I saw a second room, it would make me

1:04:56

anxious that it's not filled. You

1:04:58

know what I mean? So that's, that's

1:05:00

number, that's probably the main thing that

1:05:02

I'm doing. I think number two is actually

1:05:05

kind of narrowing my focus and narrowing

1:05:07

down my skills. Like I, I

1:05:09

like doing spine injections, but I don't

1:05:11

think that it's necessarily something I have

1:05:13

to pick up again. So, kind

1:05:16

of narrowing my focus and, I don't want

1:05:18

to say give up, but I am kind of giving up

1:05:20

one part of my practice in order

1:05:22

to make this work. That was a real, I

1:05:25

think that was a real, that's probably a big barrier

1:05:27

for some people because I

1:05:29

think if you're going to have an interventional

1:05:31

pain practice, It's very overhead

1:05:33

heavy. And I have met some people

1:05:36

trying to do the same thing and. And

1:05:38

they had to kind of convert back into some sort

1:05:40

of hybrid. So you have to kind

1:05:42

of be okay with, with either managing

1:05:44

the overhead or, giving it up for a little while.

1:05:47

I think the other thing that I'm doing is that I'm,

1:05:50

I'm really trying to just

1:05:52

keep my practice as small as possible.

1:05:54

Like, I, I feel

1:05:56

the urge to get back on the wheel and just

1:05:58

make money, make money, make money, see more people,

1:06:01

so on and so forth. But I've really enjoyed

1:06:03

it. I think I could be stressing

1:06:06

out about not being busy right now. And

1:06:08

I am busy, but I think you almost

1:06:10

have to really take

1:06:12

the time when you're building up at what you're actually

1:06:15

earned back. I've, I've been

1:06:17

in practice or in business now since

1:06:19

for the past four and a half months, and

1:06:21

I've. my kids

1:06:24

go off to school and come

1:06:26

home every day since then. I've, I've even driven

1:06:28

them. So I,

1:06:31

and I've probably spent the most time

1:06:33

with my wife that I ever had than I ever have,

1:06:35

which is great to like having lunch with them. So

1:06:38

I think really starting to actually appreciate

1:06:40

the non, Business benefits

1:06:44

is probably larger than the business

1:06:46

itself. So I've kind of curated my

1:06:48

life to kind of really just be about family.

1:06:50

As you can see, like, is, is just always,

1:06:52

always important. It's, it's

1:06:55

very easy to get busy. I'd looked

1:06:57

at some opportunities where I would be traveling

1:06:59

and expanding my practice a little bit, and I

1:07:01

automatically kind of have to draw myself back.

1:07:03

I'm like, nope. I was like, this

1:07:06

is that's not who you are. That's not why you're

1:07:08

doing this. We, of

1:07:10

course, I'd like to help people. And of course, we all we all like

1:07:12

to, to have really gainful

1:07:14

employment and things like that. But I

1:07:17

think you have to find what something else

1:07:19

that's not practice related to

1:07:21

anchor you. I think that's, that's at least for

1:07:23

me, that's, that's what's really helped

1:07:25

out.

1:07:26

And I think it really speaks to you

1:07:28

valuing yourself. You're able to see that

1:07:30

about yourself also. I think that when

1:07:32

you're so, nose to the grindstone,

1:07:35

it's really hard to see things

1:07:37

like that and what is really driving your

1:07:39

future. So, That said,

1:07:41

you have said in, you've

1:07:44

said before publicly that your job

1:07:46

will never love you. And you talked about

1:07:48

the, the timers that you've had on your phone,

1:07:50

whether it be your son turning 18, so you could

1:07:52

retire from medicine or other timers.

1:07:55

I want to ask specifically about your

1:07:57

direct care practice now. One,

1:07:59

do you have a timer and what is

1:08:01

that timer for if you have one? And

1:08:03

do you and do you find that

1:08:06

that statement is still true, that your job will never love

1:08:08

you because you're a direct care doctor?

1:08:11

That's a great. That's a really good question.

1:08:13

I the time I still have one

1:08:16

timer. That's for my son when he when

1:08:18

he's when he graduates. I think that's just

1:08:20

more for it actually more probably makes

1:08:22

me more sad because it's just like, them leaving

1:08:24

the nest is getting, closer and closer. But

1:08:26

in terms of like, will my job

1:08:28

ever love me back? It's not

1:08:30

the job that loves me back. I think

1:08:33

it's I think that the patients actually

1:08:35

love me back more or I shouldn't say love.

1:08:37

But like, I feel I feel the patients

1:08:40

more than I ever used to. I

1:08:43

used to be ashamed of or she I am

1:08:45

ashamed of it now. But like, I

1:08:48

would see people at the grocery

1:08:50

store and I would like, I'd be like,

1:08:53

I did give him enough time and you're just like, Oh, like

1:08:55

I would kind of cower because I was like, I

1:08:57

forgot their name or like, did I, did I,

1:08:59

was I short with them when I, that sort of thing. And,

1:09:02

I, I think being

1:09:04

more connected to people was a big driver.

1:09:07

So I think, and that's the way, I

1:09:09

guess it kind of lulls me back is that I'm allowing

1:09:12

people to connect with me and maybe that's a

1:09:14

better way to say it is

1:09:16

that I feel probably more connected to people

1:09:19

in general than I ever have before. And

1:09:21

that was really one of my, that was one

1:09:23

of my strengths. Prior to medical school,

1:09:26

it was like at my ability to connect with people.

1:09:28

And so I, in terms of, is it

1:09:30

ever going to love me back? I'm like, well, at least,

1:09:32

at least I, I'm now giving the job,

1:09:35

an opening to, to feel something.

1:09:37

So I think I was just like, like

1:09:40

everyone else. I was just so numb for such a long time

1:09:42

that I just kind of forgot, like forgot who I was.

1:09:45

But yeah. Yeah, I'll I'll tell

1:09:47

you this, like, real quick, it's just on my mind,

1:09:50

the year prior to

1:09:52

me actually leaving I was getting,

1:09:54

like, these weird, like, chest pains, right,

1:09:57

and, like, I'm, I'm, I'm kind

1:09:59

of a grinder, like, and I'm, like, I'm fine,

1:10:01

workout, do this, I, I'm fine, and

1:10:04

so then I was, like, I keep getting it, and

1:10:06

I was, like, it would, it would, I'd be

1:10:08

in the middle of clinic, and I'd be, like, I'll

1:10:11

be right back, and then I would leave.

1:10:13

I'd come back, drink some water. I'm fine. I

1:10:15

was like, okay, it keeps happening. And then all of

1:10:17

a sudden I, I saw my primary, I did the,

1:10:19

saw cardiologist, stress test, normal,

1:10:21

normal, normal. The

1:10:24

day I decided to quit was

1:10:28

the last time I ever had that chest pain. And

1:10:31

to me, I was just like, wow,

1:10:34

I and even as I'm a very introspective

1:10:36

person, and that to me was like, very,

1:10:38

very eye opening. It never occurred

1:10:40

to me that that's what that was, but,

1:10:43

I think overall, it's, it's,

1:10:46

it's just, it's been a crazy, crazy journey.

1:10:48

I mean, I, I really I'm really glad

1:10:51

I woke up, I'm glad that my my

1:10:53

kids honestly, they would

1:10:55

ask me what's wrong, and I would kind of, I'm,

1:10:57

I'm glad I listened to them. So I'm

1:10:59

just very thankful.

1:11:02

Amazing. Well, we are all thankful

1:11:04

for you sharing your journey today. Thank you so

1:11:06

much, Dr. Bargaras

1:11:07

absolutely. Thanks for having me on.

1:11:13

Thank you for joining us for another episode of

1:11:15

My DPC Story, highlighting the physician

1:11:17

experience in the world of direct primary

1:11:20

care. I hope you found today's conversation

1:11:22

insightful and inspiring. If

1:11:24

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1:11:26

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1:11:48

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1:11:50

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1:11:53

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1:11:56

com. Until next week, this is Maryal Concepcion.