Best ways to build up a practice

[PODIATRYCRAZE]

Pretty sure this can apply to all doctors on a production based incentive. Private practice, hospital, new doctors, solo practices, multi specialty. Even if you inherited a patient base, if you are not getting enough new refers this thread could help.

Just wanted to start a thread and learn about how to gain a patient base. Starting from the obvious ways to some more subtle ways.

Starting off with ones that I am doing:

Be ethical and good to your patients. Word of mouth is one way of getting your name out there.

Hanging out in hospital doctor’s lounge. Weird as hell but I go up to random hospitals and relevant specialties introducing myself and giving out my business card. Seen results with this for inpatient consults.

I put up signs in my hospital saying I am new in town and to text me about any foot problems. Very good results once again for inpatient consults.

Reminder that inpatients do follow up with you outpatient usually. So doing hospital work is one way to build up.

For consults or referrals. Getting seen quickly with a fast and efficient discharge plan helps a lot. Taking 1 week to do a debridement and closure vs 10 days. The hospital and medical team will be happier the quicker you do things.

Visiting the emergency department and internal medicine residents to introduce myself. These guys will always try and throw away their feet if they get a chance.

I am pretty social when I am in the operating areas. Mainly so I can meet with orthopedists and vascular guys. Literally asked orthopedics if he gets a lot of dirty foot consults he doesn’t want. Said yes but that he already employs a podiatrist. Vascular has always been good to me.

Internist told me word for word “business cards are the cheapest form of advertisement, use them”

I never see billboards for podiatry. I wonder why.

Here are some that I heard of:

Being present in the community. Going to church, block parties, community events.

Accepting more insurances. My job did this for me, but it can be hit or miss depending on your location and payer mix.

Ask your new patients how they came to your office. If it was from another doctor’s referral, send them a letter or message to thank them. Also give them a report on what you found and did for the patient.

Considering doing but have not done yet:

My marketer is supposed to visit local relevant doctors, and primary to tell them. If you don’t have a marketer do it yourself. We have all seen it before, just drop off cookies or something. Make sure you get some face time.

Putting up more signs and giving floor nurses some snacks and remind them to check feet. If they find anything, ask hospitalist to consult us.

Going to other podiatrists and letting them know if they need a second opinion, or if they don’t like doing surgery/certain procedures to send my way.

List of specialties to try: family, orthopedic, vascular, dermatology, endocrinology, infectious

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[HardRoadPaved]

It's threads like these that make me realize that doctors must be the most anti-social, narcissistic, poor business minded people out there.

Literally asked orthopedics if he gets a lot of dirty foot consults he doesn’t want. Said yes but that he already employs a podiatrist.

Why are you groveling for that garbage? When you build up your nice practice, do you really want that stuff stinking up your waiting room?

 

[PODIATRYCRAZE]

It's threads like these that make me realize that doctors must be the most anti-social, narcissistic, poor business minded people out there.


Why are you groveling for that garbage? When you build up your nice practice, do you really want that stuff stinking up your waiting room?

Yes. I actually do prefer dealing with dirty cases. Orthopedic reconstructve surgeries are not as fun for me.

Also, can you tell me what I need to do or am doing wrong?

 

[Feli]

Try owning the practice (or true partner). That's the best way I've found.
You can make meaningful and immediate changes and see how your strategies work. You don't get your ideas neutered or limited or vetoed.

The more you build up some other guy's practice, you can learn a bit... but you are just frustrating yourself and lining other ppl's pockets. Do that associate crap for the shortest time possible.

...I agree above on not stupid asking and angling for the crap visits. The nails, wounds, MCA junk, walk-ins for nonsense will find you even if you try to hide from it... so it's stupid to go looking for MORE of it. You will realize that once you're more than 2 months into practice, lol.

 

[GreenHousePub]

Man all of that stuff sucks.

Wait - are you working as an associate doing all of that stuff?

 

[PODIATRYCRAZE]

Man all of that stuff sucks.

Wait - are you working as an associate doing all of that stuff?

Yes. On a day like today, my surgery day was light. Only 1 case in the morning. And I have the rest of the day to myself. But I want to get busier.

 

[air bud]

Yes. On a day like today, my surgery day was light. Only 1 case in the morning. And I have the rest of the day to myself. But I want to get busier.

Sounds like you need to learn how to bake better cookies

 

[HardRoadPaved]

Yes. I actually do prefer dealing with dirty cases. Orthopedic reconstructve surgeries are not as fun for me.

Also, can you tell me what I need to do or am doing wrong?

I mean to each their own. You can do plenty of "clean things" without being a total toenail replacement specialist or dive into orthoplastics. (warts, ingrown, sprains and strains).

I just never understood why you need to fill your waiting room with train wrecks and burn out when they call you for the 2am toe amp.

 

[air bud]

I mean to each their own. You can do plenty of "clean things" without being a total toenail replacement specialist or dive into orthoplastics. (warts, ingrown, sprains and strains).

I just never understood why you need to fill your waiting room with train wrecks and burn out when they call you for the 2am toe amp.

Sir see the meme thread for our responses to 2AM amps

 

[BubbaWub]

Sounds like you need to learn how to bake better cookies

I am debating opening up a cookie making workshop at the next conference I attend for future residents. This will help garner business and spread awareness of podiatry. My Mormon colleagues have wives that make incredible cookies that would leave a person speechless. They have taught me some of this dark magic for a tithing.

I am sure some organizations would be willing for me to demonstrate my skills and knowledge and pass them on to the next generation of foot and ankle orthopodiatric surgeons.

Thank you

 

[GreenHousePub]

Yes. On a day like today, my surgery day was light. Only 1 case in the morning. And I have the rest of the day to myself. But I want to get busier.

You are building a lot of value to the practice! My wife tells me you are really good with the medical assistants as well. Your bonus this year will reflect your hard work in building my practice.

 

[AttackNME]

It's threads like these that make me realize that doctors must be the most anti-social, narcissistic, poor business minded people out there.


Why are you groveling for that garbage? When you build up your nice practice, do you really want that stuff stinking up your waiting room?

Because that’s how I make over $500k a year

 

[pod squad]

Because that’s how I make over $500k a year

 

[Feli]

Man all of that stuff sucks.

Wait - are you working as an associate doing all of that stuff?

Concur. ^^

Goals for podiatry associates in pod supergroup or any size DPM groups:

1. Realize it's a **** sandwich situation (do not be ok with a boss feeding 'protocols' and getting 1:2 ROI - or worse - on your education), but also know it's temporary and you can learn from it.
2. Treat your patients well, develop your style. Hone your skills and your own "protocols." Do your job, but you have little reason to excel and work long hours and inflate the revenue for someone else's biz and gains. Be a yes-man to boss's fat face obviously.
3. Learn billing. Ask questions of the biller and the owner and other docs working there. Read on it. That said, the PP boss has 542 ways to screw you, hide numbers, change the numbers, say you hit minimal or no bonus, justify why you take call or work Saturdays and he does not, whatever. Just go with it; it's terrible internship or fellowship of sorts which most DPMs will have to do. Our job market is awful.
4. Get ideas about what goes well and what could go better for the office you work at and offices overall (staff/training, products, services offered, efficiency/logistics, organization, marketing, supplies, whatever). Make lists of supplies. Get ideas.
5. Marketing and networking is fine, but do it to learn and practice it for YOUR gain and your skill, not just to build the current practice (which you work at, you do not own). Fyi, you won't reliably see what works and doesn't for marketing until many months later on. Spoiler: meeting PCPs and doing good work goes the furthest for the longest and costs the least. Get good at that.
6. Look (discreetely) for higher salary from DPM hospital/msg/supergroup jobs at least once per week, apply to good ones, follow up. Cold call facilities or MSGs in areas you like or would tolerate. Keep it up. Do it every week if you want that work and will put up with the call. Look hard every week. The longer you stay and languish in PP, the harder it'll be to get hospital jobs (even if you get ABFAS cert while in PP).
7. Look (discreetly) for offices to buy out or develop startup plans if you're wired that PP way, and start lists and rough budget needed to start up solo someday. Look into noncompetes for your current area or where you may go. Talk to attorney prn. Begin with the end in mind. Consider ECF work if you have to do it to make ends meet early.
8. Be smart with your money. Live like a resident. Early on, make minimum loan pays (IBR or similar), and mainly just get solid startup/move/EF savings built up. Definitely don't be stupid and "buy" a new car - or worse, a house... great way to chain yourself to the crap job and never get a raise again when boss sees a 2024 Jeep or staff tells him you went from apartment number to house address or he finds out your kid is in private school and knows you're rooted there. Dude hired you for one reason: to make money off of you.
9. GTFO to a better job or starting your own office. Screenshot/download your surgery pts beforehand for ABFAS; be aware you might be fired right after you give your quitting notice.
10. Be amaaazed if you get treated fair, paid remotely fair for more than a year or two, or offered true partnership by Dr Moustachio.

 

[dtrack22]

Pretty sure this can apply to all doctors on a production based incentive. Private practice, hospital, new doctors, solo practices, multi specialty. Even if you inherited a patient base, if you are not getting enough new refers this thread could help.

Just wanted to start a thread and learn about how to gain a patient base. Starting from the obvious ways to some more subtle ways.

Starting off with ones that I am doing:

Be ethical and good to your patients. Word of mouth is one way of getting your name out there.

Hanging out in hospital doctor’s lounge. Weird as hell but I go up to random hospitals and relevant specialties introducing myself and giving out my business card. Seen results with this for inpatient consults.

I put up signs in my hospital saying I am new in town and to text me about any foot problems. Very good results once again for inpatient consults.

Reminder that inpatients do follow up with you outpatient usually. So doing hospital work is one way to build up.

For consults or referrals. Getting seen quickly with a fast and efficient discharge plan helps a lot. Taking 1 week to do a debridement and closure vs 10 days. The hospital and medical team will be happier the quicker you do things.

Visiting the emergency department and internal medicine residents to introduce myself. These guys will always try and throw away their feet if they get a chance.

I am pretty social when I am in the operating areas. Mainly so I can meet with orthopedists and vascular guys. Literally asked orthopedics if he gets a lot of dirty foot consults he doesn’t want. Said yes but that he already employs a podiatrist. Vascular has always been good to me.

Internist told me word for word “business cards are the cheapest form of advertisement, use them”

I never see billboards for podiatry. I wonder why.

Here are some that I heard of:

Being present in the community. Going to church, block parties, community events.

Accepting more insurances. My job did this for me, but it can be hit or miss depending on your location and payer mix.

Ask your new patients how they came to your office. If it was from another doctor’s referral, send them a letter or message to thank them. Also give them a report on what you found and did for the patient.

Considering doing but have not done yet:

My marketer is supposed to visit local relevant doctors, and primary to tell them. If you don’t have a marketer do it yourself. We have all seen it before, just drop off cookies or something. Make sure you get some face time.

Putting up more signs and giving floor nurses some snacks and remind them to check feet. If they find anything, ask hospitalist to consult us.

Going to other podiatrists and letting them know if they need a second opinion, or if they don’t like doing surgery/certain procedures to send my way.

List of specialties to try: family, orthopedic, vascular, dermatology, endocrinology, infectious

lol I did this stuff as an associate in a small podiatry group after finishing residency…still didn’t bonus.

If you are an associate in a podiatry group, don’t do any of this. This is what you do when you start your own practice. Then it actually correlates to an increase in income. When you are getting paid by another podiatrist, you sit back and do nothing, collect your base salary (because that’s all you’re gonna make despite all of this marketing BS) and spend your time applying to hospitals or planning the start up of your own practice. Don’t waste it marketing for a practice that’s already taking 70-80% of every dollar you bring in. They should be marketing for you, it’s part of the practices overhead $ that is already taken from your collections.

 

[PODIATRYCRAZE]

I made a post awhile back asking for rough estimates on certain procedures. From my small sample size I gave estimates. I cannot remember many, if any other solid numerical contributions.

Why do I like limb salvage cases? To me it is more fun and gratifying. Saving a limb vs saving a hammertoe. Not to mention the monetary side. 0 day global for a debridement vs 90 days for a bunion. If the bunion makes $600 for 90 days, then the serial debridement and subsequent procedures and visits will easily pass the $600.

Once again here. I asked for tips. Not a single real one. Yes I get it’s the internet. Trolling is fun. And some sarcastic comments about forgetting it because I won’t bonus much if at all.

My goal is always to learn more both about podiatry and business. I am aiming to bonus within my first year even if it is unattainable. No harm in trying my best. On that note. I am positive that I will bonus within my first 6 months. I made this post seeking suggestions on how to maximize that bonus.

Just thought of a couple more tips.

Try arranging rep dinners with other local providers.

Hobbies. Golf and tennis not for me. But I might try inviting some guys out for fishing.

 

[AttackNME]

I made a post awhile back asking for rough estimates on certain procedures. From my small sample size I gave estimates. I cannot remember many, if any other solid numerical contributions.

Why do I like limb salvage cases? To me it is more fun and gratifying. Saving a limb vs saving a hammertoe. Not to mention the monetary side. 0 day global for a debridement vs 90 days for a bunion. If the bunion makes $600 for 90 days, then the serial debridement and subsequent procedures and visits will easily pass the $600.

Once again here. I asked for tips. Not a single real one. Yes I get it’s the internet. Trolling is fun. And some sarcastic comments about forgetting it because I won’t bonus much if at all.

My goal is always to learn more both about podiatry and business. I am aiming to bonus within my first year even if it is unattainable. No harm in trying my best. On that note. I am positive that I will bonus within my first 6 months. I made this post seeking suggestions on how to maximize that bonus.

Just thought of a couple more tips.

Try arranging rep dinners with other local providers.

Hobbies. Golf and tennis not for me. But I might try inviting some guys out for fishing.

Real world tips for someone who likes limb salvage? Use skin subs, basically someone with Medicare and a secondary, do you use them? They help patients a bit and it makes you a lot of money. Do it now before the LCDs change next year on skin sub policy. That aside, debriding wounds with bone and tendon exposed are major money makers too. If you bring all your limb salvage cases to clinic after i&d, seeing them in office for weekly debridement, that helps build your practice quickly too. Just saying yes to every ER or hospital consult will help spread your name quick especially if no one else wants to do this stuff. Being able to take care of complex wounds in office helps too, do you feel comfortable treating distal toe tip osteo on oral abx? That’s a level 4 e/m with 25 modifier and a 11044, after infection gone, do a flexor tenotomy and then keep doing debridements with 58 modifier til healed

 

[Feli]

... distal toe tip osteo on oral abx? That’s a level 4 e/m with 25 modifier and a 11044, after infection gone, do a flexor tenotomy and then keep doing debridements with 58 modifier til healed

I don't think they will pay 28010/28232 after the 28825 clears that osteo infection 😀

 

[Feli]

...I asked for tips. Not a single real one. ...

Dude, you are gonna make WELL over $300k - probably over $500k, remember??? That is GigaChad dominance, young bro.

What do you need our help for? You should be lecturing on this stuff (as you do coding). We should be asking you stuff! 🙂

...It's the internet... don't take it too seriously.
You are getting "real tips": don't put too much effort into building another guy's wealth and biz. It's the practice's job to market/schedule you. That is the main tip. You are there to work and learn. I gave you tips, so did dtrack, GHP, and so did others above. The forum has a search with hundreds more tips. Relax and enjoy being the first DPM to make a fat half mil in your first year out... bigtime USD to buy crypto and still having time to invite PCPs fishing!!! 👍🐟🐡🐟🎣🐟🐟

 

[AttackNME]

I don't think they will pay 28010/28232 after the 28825 clears that osteo infection 😀

Saving the toe keeps the patient happy and you get paid wayyyy more money, but you do you bro

 

[GreenHousePub]

Try arranging rep dinners with other local providers.

This is where you show that you are very inexperienced. I hate going to rep dinners now that I have been out for a while.

They are a waste of time. A $50 dollars meal that takes up like 3-4 hours of my time to hear some advertisement and then get harrased for weeks afterwards.

Also: stop referring to it as "your office" if you are an associate. It is "his office," and should help you put it in perspective.

 

[air bud]

This is where you show that you are very inexperienced. I hate going to rep dinners now that I have been out for a while.

They are a waste of time. A $50 dollars meal that takes up like 3-4 hours of my time to hear some advertisement and then get harrased for weeks afterwards.

Also: stop referring to it as "your office" if you are an associate. It is "his office," and should help you put it in perspective.

Dinners are cool as a poor resident....now hell no I don't have time for that

Also listen to what everybody has told you. Keep expenses low you're going to be there for a year learn as much as you can start planning your exit now. Don't work for another podiatrist. You're clearly smart. you can do this on your own and then keep all the money and have autonomy.

 

[dtrack22]

Once again here. I asked for tips. Not a single real one. Yes I get it’s the internet. Trolling is fun. And some sarcastic comments about forgetting it because I won’t bonus much if at all.

It wasn’t sarcastic. It was a tip. Spending your valuable free time building up a practice that pays you 20 cents on the dollar is bad business. And you are in private practice, which means you need to be just as much a businessman/woman as you need to be a podiatrist. If not more so.

Tip: don’t go out of your way to market and make someone else money, especially when they are taking money from you in order to pay for those services already.

 

[619]

lol I did this stuff as an associate in a small podiatry group after finishing residency…still didn’t bonus.

If you are an associate in a podiatry group, don’t do any of this. This is what you do when you start your own practice. Then it actually correlates to an increase in income. When you are getting paid by another podiatrist, you sit back and do nothing, collect your base salary (because that’s all you’re gonna make despite all of this marketing BS) and spend your time applying to hospitals or planning the start up of your own practice. Don’t waste it marketing for a practice that’s already taking 70-80% of every dollar you bring in. They should be marketing for you, it’s part of the practices overhead $ that is already taken from your collections.

I did the same too. Fresh out of residency in a small pod group, they opened a new satellite clinic ( 2 days a week) in a rural town next to a small rural hospital and that was meant me be my future main office when it grows. I was so excited and I did all the marketing that OP mentioned without anyone requiring me to do it. On a slow day with 3-4 patients, I was out on the field marketing and driving around with on my gas and putting countless miles on my car. I started out at the rural clinic with 2 staffs (one front desk and one MA). I was even the one that opened the google my business page for the clinic after a few months just to get more traffic when I noticed the office was not showing up on google since it's a new location and address. I grew the review page with 5 star reviews and it was easy to rank at the top since it's a small town. The patients were flowing in and we soon added more clinic days.

I did not regret doing all that because when I went solo and opened my own clinic, it was very easy for me to hit the ground running with marketing and building patients. I knew from my last gig that it was pointless doing ER work and taking hospital consults or looking for diabetic nails. As feli said, those ones will find you. I focused my marketing to PCP on heel pain, ingrown nail, sprains, MSK pathology etc. I was able to start with one front office start and no MA because of the experience I gained. Starting out, I had no trouble taking my x-ray, cleaning my exam room, instrument set up, autoclaving etc. Obvious I set my google my business page for my own office, built up 5 star reviews and was able to rank #1 in a few months (in a saturated metro with 2 super pod groups offices less than a mile away and countless other solo offices around) all for zero dollars.

 

[NatCh]

At Christmas time put on a Santa hat and deliver foot cookies to all of the other medical offices...

 

[Weirdy]

Keep it friendly.
Lots of good advice and discussion on here.

 

[wakaflocka88]

First job. I paid for FaceBook advertising to focus on target demographics in my town. You specify how much money is used and it will tell you a relative customer acquisition cost. The more you spend the greater the reach. Guess what. Spent hundreds of my own money and it yielded a zero return. I printed out flyers with all the insurances I accepted, services offered, in color with business cards. Generated minimal referrals.

In the end I wasted money and valuable time with minimal return on the investment.

If we were not saturated the above likely would have been very beneficial.

 

[GreenHousePub]

First job. I paid for FaceBook advertising to focus on target demographics in my town. You specify how much money is used and it will tell you a relative customer acquisition cost. The more you spend the greater the reach. Guess what. Spent hundreds of my own money and it yielded a zero return. I printed out flyers with all the insurances I accepted, services offered, in color with business cards. Generated minimal referrals.

In the end I wasted money and valuable time with minimal return on the investment.

If we were not saturated the above likely would have been very beneficial.

Did you take out ads with your own money for someone elses practice though?

 

[wakaflocka88]

Did you take out ads with your own money for someone elses practice though?

The ads I created via Facebook had my image, linked to my own business page but yes the location is another persons practice 😉

 

[GreenHousePub]

The ads I created via Facebook had my image, linked to my own business page but yes the location is another persons practice 😉

 

[Sole Badguy]

Maybe learn a second language? Would be especially beneficial since you're based in NYC; I'd recommend Spanish or Chinese.
Sure there's medical assistants or even telecom translators but it's not quite the same IMO.

 

[GreenHousePub]

Maybe learn a second language? Would be especially beneficial since you're based in NYC; I'd recommend Spanish or Chinese.
Sure there's medical assistants or even telecom translators but it's not quite the same IMO.

I'm gonna make a follow up meme for this as well.

 

[GreenHousePub]

Hats off to you though, lately I've been bored with SDN and was almost about to delete the account, but this newfound absurdity/hilarity has given me a second wind.

 

[podourology]

Maybe learn a second language? Would be especially beneficial since you're based in NYC; I'd recommend Spanish or Chinese.
Sure there's medical assistants or even telecom translators but it's not quite the same IMO.

Senior, tengo dolor en los dedos. por favor Corte las unas. *patient then runs finger across each individual nail*. Por favor mas corto.

 

[heybrother]

This thread has answered a lot of questions for me. Yes, if you are doing a lot of 11043/11044 in the office - you are going to have higher collections.

11044 is one of those codes that makes it clear how broken the toe amputation and I&D codes are.

 

[GreenHousePub]

Senior, tengo dolor en los dedos. por favor Corte las unas. *patient then runs finger across each individual nail*. Por favor mas corto.

When they start grabbing an individual nail and pulling their foot up, I always start cutting the nails on the other foot to not waste time.

Sometimes they alternate like 3 times but by that point I'm already done.

 

[deleted1162946]

When they start grabbing an individual nail and pulling their foot up, I always start cutting the nails on the other foot to not waste time.

Sometimes they alternate like 3 times but by that point I'm already done.

So we all live the same life

 

[Adam Smasher]

Once again, I'm late to the party, it's been a tumultuous few weeks in my practice. It's a story worth sharing, so maybe I'll post on that after it's all in the rear view mirror.

In terms of building a practice, the single most important thing you can do is FIND A LOCATION WITH ROOM TO GROW. I decided early on in residency that I would not put up with the saturation abuse just to live in any particular city. You don't necessarily need to live miles from civilization to have a successful practice. Where I live, the weather is bad-to-ok, the restaurant scene is decent, and there are cultural offerings within a reasonable drive. Cost of living is high and my payer mix is awful, but I operate on high transactional velocity, so I might not always get paid what I deserve for my time and skill, but there's a steady volume of patients keeping me profitable. Feli says the trifecta of private practice is being outgoing and friendly, good payer mix, and being in an unsaturated area, and my experience is that you can get by with the last one if you don't have the first 2. 😉

If there are other DPMs in town, it's not necessarily a bad thing. Past a certain age, most of us hope to scale back and see fewer patients. Typically in life, we hit a time in our 40s or 50s where we accomplish all the goals (financial, career, personal) we wanted to achieve in life so what's the point of struggling more. Or maybe we don't have the drive/energy to do it. If the other docs in town only want to work from 9 to 3 so they can coach little league or do whatever, that means you can build a practice along side them simply by making yourself more available. If you find yourself violating your own boundaries to undercut other area DPMs, you've found a bad area--you need to move.

The single best way to market yourself to area PCPs and Urgent Cares is to just drop off your business card, show your face, and say "I'm new in town, have same-week availability if your patients need anything." No cookies, no 1-hour luncheon. Mention ingrowns, warts, gout flares, heel pain, wounds (if you like them). And then just wait, patients will come your way via osmosis. If there's 3 other DPMs in town who also have same-week availability, you're in a bad area--you need to move.

There was a dermatologist starting out in town and did a luncheon for us about a year ago. I do diagnose malignancies every now and then, but this guy didn't accept medicaid so I couldn't send him those cases. I have referred him 2 patients for recalcitrant tinea pedis, that's it. That's why you don't do luncheons.

Keep your advertising budget lean. The return on investment isn't there. At least it hasn't been for me. Having a website that is search-engine optimized is important. Put QR codes on your business cards that direct people to the site. Every other form of advertising isn't going to translate into enough patient leads to justify the cost. The only other benefit of advertising is that the more you advertise, the more you "mark your territory" and potentially discourage competition from moving into your terrain. It's extremely difficult to determine what's the return on this investment or if it even works.

Giving seminars in the community isn't a great use of your time. I would end up getting an onychomycosis or heel pain referral out of it but not much else. If I wanted to try to push laser/shockwave/orthotics/retail garbage maybe it makes more financial sense to do this, but there are more productive uses for your time otherwise.

People will disagree, but I have a firm policy of keeping podiatry off of my social media and vice-versa. A few doctors become tiktok famous but most of them just make themselves look silly. You have a tremendous ability to damage your reputation via social media.

Another thing people will disagree with: hustling for inpatient consults can work to your benefit. You do your 2 am toe amputation, get your patient healed and on their feet again, internists and PCPs WILL notice. You get a reputation for being someone who is conscientious and concerned for their patients, and that is worth solid gold. Yes, you have to play the long game to get there, and yes, your employment situation might preclude you from ever reaching that point, but that's the gamble. Besides, I believe it's a better use of your time to do inpatient work than to pound the pavement trying to direct market your laser/shockwave/orthotics/retail garbage. Just my opinion.

And this brings me to the associate-owner relationship. I don't have associates working for me, but I don't understand how it makes any sense to screw associates out of their bonuses. If you have an associate, you WANT them to bonus. You WANT them to be rewarded for their efforts and have a reason to expand the practice on your behalf. If you screw them out of it when the year is up, they're going to leave and now you have to find someone new. How do you grow your business doing that? I'm not saying this doesn't happen, I'm just saying I don't understand the practice. Consider 3 scenarios.
1. Your associate doesn't see a single patient. This is just like buying a shockwave unit and not using it at all. You're paying their salary and getting no return on the investment. Obviously you need them to work otherwise, why hire them?
2. Your associate sees exactly enough patients to meet but not exceed their bonus threshold. They've covered their salary and their overhead, possibly made some money for you but not much. This is no different from you opening up and managing the practice of a second doctor. Not a good use of your time. If this is what you want, why hire them when you could just tell them to go out and hang their own shingle to reach the same financial result?
3. Your associate sees as many patients as they can, generates as much collections as they can. You need to pay X% bonus. If you're annoyed about that, you're a *****. This person has generated (1-X)% marginal profit. If you don't understand that, give up, business is too complicated for you.

What's crucial is that if both the owner and the associate want to hustle, and if everyone is properly incentivized, it's not necessarily bad if you market on behalf of your employer. There is such a thing as shared success. Yes you're promoting someone else's business and accruing a benefit to them but ultimately it's your face and your reputation you're putting out there. There's potential for everyone to win IF everyone has the same goals. (Lazy owner + hustler associate is a bad mix. Lazy owner + lazy associate is even worse.)

Lastly, if you're hospital employed, you can disregard the above, because you're already playing the game in cheat-mode. 🙂

 

[Adam Smasher]

interesting, the forums censored the word Moe-Ron in my post above. Sorry, Weirdy

 

[Feli]

I would say it depends on the area.
Some things that work well in one place are a total waste in another situation.
Billboards or direct mail or other stuff can work in bigger cities; sponsoring sports team or showing face at community events is a smaller town move.

In a metro, large city, big hospitals, whatever... docs come and go, you have MUCH competition, many docs are hospital or MSG employed. The refer patterns are sometimes fairly ingrained, so you have to take the shotgun approach and hope you get hits occasionally. You can't waste time trying to connect with docs that won't ever refer - or aren't allowed to, even if they wanted to. The best bet is PCPs who are in PP also (hospital PCPs likely have to refer to hospital DPMs). Regardless, there are tons of options for podiatrists in metros. In those areas, it is best to just buzz around, drop off cards/brochures/gifts at many places (med offices, PT places, UCares, pedicure shops, whatever), and hope for the best... obviously go back if a place responds well or sends you pts.

In small/medium towns, it is well worth trying to converse with docs (mainly PCPs, but specialists too) in the cafe, OR lounge, staff meetings, doc lounge, hallways, community, wherever. Most smaller town folk eschew the corporate marketing approach and the free lunch. Personal relationships are key; people know one another in smaller areas. Build rapport. Know their story. Tell a bit of yours. Give the docs your cell number to communicate on mutual patients or if they need someone seen same day. Send them occasional XR before/after or progress notes with a handwritten note on it. Send snacks or token holiday gifts for their staff to say thanks for the refers (weird vibe without a relationship, but good effect once you know them). Personal relationships that are difficult to make and/or fruitless in bigger areas can be fairly easy to make and over time, those connects get you almost bulletproof to competition in the more rural setups.

...The begging for inpatient is absolutely duuuumb unless that's the kind of stuff you want and the part of your practice you are looking to grow ("eff no" in my case). That stuff only leads to bad hours, bad insurance, big stinky wounds in your office. No thanks. It's akin to buying a jacket that says "SEND RAM'S HORN NAILS TO ME." You will get a bit of that junk even if you try to avoid it, so why actively encourage it???

...Feli says the trifecta of private practice is being outgoing and friendly, good payer mix, and being in an unsaturated area, and my experience is that you can get by with the last one if you don't have the first 2. 😉...

Yes, but ideally you want 2/3 of those or even all 3 of those qualities...

Sadly, it only takes one or two full-time DPMs incoming to make an unsaturated area balanced or even relatively saturated for podiatry. The more rural an area, the less hours of office from new DPM(s) it'd take to disrupt existing DPM(s). With 700+ yearly grad DPMs now cold-calling for hospital gigs and looking for jobs and more and more DPM large and supergroups, no area is really "safe." More than a couple of my co-residents did exactly that: planted a flag via PP or hospital job in fairly rural area and took over. It's very easy for even smallish hospitals to make a satellite clinic, and it's dirt cheap for a group to add a suburbs office or a doc to do DPM solo startup in most rural places. Hospitals will typically help them. It's lame, but even east Oregon or Wyoming or Dakotas are no longer safe. Podiatry is oversupplied. Ergo, the likable doc part can stonewall incoming competition (refer sources are loyal to you, new competitor office sputters), and the good area payers allows for a volume dip to not be too troublesome as per-pt is still pretty good.

Without the good payer mix, you are stuck seeing high volume and/or doing the game of dumping unnecessary DME and/or wound cares on MCR/MCA pts who don't check their EOBs (as private pts usually do). That is no bueno imo. And sure, it is what most DPM offices do: bomb on MCR/MCA with "grafts" and custom braces and fancy injections and etc. It works, and it pays the bills... but it is lame and a big audit target and forces those docs to always chase "new codes" imo. Many pod PPs have already taken clawbacks on wound "graft" nonsense, and that party is basically coming to an end soon. They will find new ways to bill on MCR/MCA, but you'd typically prefer to just do what pts actually need, do mostly the pathologies you want, and get paid well by PPOs and simlar for it (less pts volume for same income).

 

[Retrograde_Nail]

Have great training and be able to treat everything from toenails to TARs to muscle flaps to charcot/ex fix to MIS bunions to arthroscopy. Do it all.

Do wound care. Do it all.

You will never run out of business.

 

[Weirdy]

interesting, the forums censored the word Moe-Ron in my post above. Sorry, Weirdy

Youre fine. I have no control over that. Its an autoscript. I cant even call myself a *******

 

[heybrother]

You are a brand new private practice owner who has gone out on their own. You put in a few years somewhere else. You've somehow moved to an area with adequate payors. You are ready to help people and ready to keep the fruits of your labor.

A same day patient comes in. They have a BCBS plan from their employer, Walmart - its a real thing. They have an ulceration on their 2nd digit, diabetic neuropathy, a contracture of the toe, and are a good candidate for a flexor tenotomy. You sign them up for a flexor in 7-10 days when they can get off to come back in, subQ debride, and bill a 99204 and 11042. You are excited to help this patient resolve their ulceration and excited to have one of those good clinic encounters that helps keep the lights on. That patient returns to your office for their flexor tenotomy and low and behold - they owe your office $360 for the services already rendered. You know your fee schedules and you know that Medicare reimburses about $360 for a 28232 which means good commercial insurance reimburses somewhere between $500-600 for the procedure. It would be very convenient for you if you could also bill a 11042 at ...some of the follow-up visits.

What will you do?
-Put them on a payment plan? They believe they can budget $20 a month.
-Not perform the flexor until the 1st visit is paid off?
-Perform the flexor, let the balance stack up, you'll collect it in time when they come to appreciate your services.
-Perform the flexor, payment is likely hopeless but its the right thing to do to spare them a hospitalization/amputation.
-Perform the flexor, but make them put money down or give you their credit card number as assurance. Do you have a credit card agreement?

Same type patient. Now the ulceration is under the 5th metatarsal head. The visits stacked irregularly and their insurance processed a little more slowly. You've had 3 visits before any processed and the patient owes you $800. They are coming in this afternoon. The wound improved, but is not closing. The patient was very clear they don't have the resources to go to the hospital or ASC for a 5th metatarsal head resection / metatarsal osteotomy because the facility wants $3K up front.

What's your plan?

A patient with a somewhat irregular hallux tip ulceration presents to your clinic. They have Humana which you've foolishly decided to accept because "PCPs won't refer to you unless you accept everything". You've debrided the ulceration and it isn't closing. You have more than adequately explored the medical and vascular component of the wound - there is no failure on your part. You ultimately opt for a flexor tenotomy and you also debride bone from the tip of the toe. The patient initially appears to be healing, but the ulceration rapidly reforms. You continue performing weekly 11042 visits, but by the time the claims process you realize you are not being paid for any of the 11042 visits even though you are using appropriate modifiers.

Where am I going with this overly long, overdrawn out, overly explained story. You have to collect from people. You have to collect from insurance companies. Great visits, great insurance, great encounters, great pathology and diversity - still has to be paid for with money. There's a moral hazard to some of what we treat. If a patient being treated for plantar fasciitis wants surgery, but can't put money down that's not necessarily the same thing as a patient with a wound who can't pay. People who are already successful, who already have patients out the door/cash flow would say its just one patient. And that's true, but presumably they already have an office manager/front desk receptionist actively asking people for money. A landslide is made up of many individual stones. None of this crosses hospital employed podiatrists minds. Of course none of this crosses your mind when the patient has Medicare and a secondary either.

Your ability to render medical care is impacted by patient's ability to pay.

 

[GreenHousePub]

Have great training and be able to treat everything from toenails to TARs to muscle flaps to charcot/ex fix to MIS bunions to arthroscopy.

Once again this obsession with "training." Fantastic residencies, fellowships, etc.

None of that translates to success in podiatry. I would say there is such a weak correlation between going to a "stellar" residency (and an even weaker to non-existent correlation with fellowships) and reaching success that it doesn't even matter anymore with podiatry.

Clinic is going to be the biggest earner by far. Getting good at clinic will translate to guaranteed success.

 

[Feli]

Once again this obsession with "training." Fantastic residencies, fellowships, etc.

None of that translates to success in podiatry. I would say there is such a weak correlation between going to a "stellar" residency (and an even weaker to non-existent correlation with fellowships) and reaching success that it doesn't even matter anymore with podiatry.

Clinic is going to be the biggest earner by far. Getting good at clinic will translate to guaranteed success.

I see both sides.

Having a lot of skills means having job options, being valuable to hospital jobs, being busy.

At the same time, being "busy" does almost nothing for income. If you can't find a facility to pay you - or pt population where you get paid, it doesn't matter. There are some areas where a lot of visits are literally losing you money in PP. I've had jobs where I see where I saw double the volume (MSG in immigrant area, tons of MCA and "self pay") in which I worked hard and thought I was going to start doing awe$ome - yet barely collected half what I do now (and now seeing half the volume).

...Your 3 main ways to succeed financially in podiatry have been the same forever (vast majority of pod groups clearly pick the middle):

• hospital/org job with group rVU model that pays indifferent to good/bad/no insurance (then work hard or minimal depending on $$ situ)
• PP with billing hard on MCR/MCA for DME and wound care and various codes/tests that pay well (and hoping people don't read EOBs and report you), writing off most coinsurance
• PP in good employed/insured area where visits pay fairly well and working age people (and their kids) pay their bills/conisurance, minimal MCR/MCA

 

[air bud]

Once again this obsession with "training." Fantastic residencies, fellowships, etc.

None of that translates to success in podiatry. I would say there is such a weak correlation between going to a "stellar" residency (and an even weaker to non-existent correlation with fellowships) and reaching success that it doesn't even matter anymore with podiatry.

Clinic is going to be the biggest earner by far. Getting good at clinic will translate to guaranteed success.

Yes.but you don't know what you don't know. Training. But let's be clear - 3 years tops. Clinic is easy. You see enough in training then you figure out clinic fiast. Training is surgery. Screw going to clinic unless no cases to scrub. You got 3 years. Max it out. You don't need to spend a ton of time in clinic ....at some point this is easy. Some combo of boot, steroid shot/dose pack, NWB, unna boot, OTC orthotics or punt it. You don't need to spend forever in clinic to learn that. Do as much surgery as you can in residency.

 

[Retrograde_Nail]

Once again this obsession with "training." Fantastic residencies, fellowships, etc.

None of that translates to success in podiatry. I would say there is such a weak correlation between going to a "stellar" residency (and an even weaker to non-existent correlation with fellowships) and reaching success that it doesn't even matter anymore with podiatry.

Clinic is going to be the biggest earner by far. Getting good at clinic will translate to guaranteed success.

Surgery pays in hospital employed jobs. I do 40-60 procedures a month.

If I was not in a hospital then my surgical volume would be lower.

I personally think you are speaking on perspective of private practice. In that case clinic prob pays you more unless you really are a wizard in the OR and can get a lot of cases done.

To say surgery and good training does not impact your bottom line is nonsense.

 

[air bud]

I am saying being a good surgeon makes you a good clinician. Retro is gonna retro

 

[Adam Smasher]

I am saying being a good surgeon makes you a good clinician. Retro is gonna retro

Good advice. I used to think of it as "bringing the OR to the office." In other words, approach patient encounters intentionally, be proactive not reactive. Have a plan for what you're going to offer them based on what you know prior to entering the room. Just like most surgeries follow a step-by-step procedural pathway, there are options for intraoperative decision making where you have to deviate from the plan. Same thing in the office. Obviously, don't be a robot, but if you can control the pace of your encounters, you're more efficient and more productive.

 

[619]

I will continue to preach the same gospel: If you are hospital/MSG employed with wRVU payment model then doing surgery/big OR cases favors you however if you are PP employed with collections/% bonus payment model then increased clinic volume favors you.

You can't be in PP and be trying to do big charcot/recon cases on a patient with MCR/MCA with long post-op course. You can't be in PP doing 2am toe amps and seeing hospital consults/ER consults on patients with no insurance. Let the hospital employed folks take care of that and be highly rewarded.