1:50

Primary care is an innovative, alternative

1:53

path to insurance driven health care. Typically,

1:57

a patient pays their doctor a low monthly

1:59

membership and in return,

2:01

builds a lasting relationship with their doctor

2:03

and has their doctor available at their

2:05

fingertips. Welcome

2:08

to the My DPC Story podcast, where

2:10

each week, You will hear the ever so

2:12

relatable stories shared by physicians who

2:14

have chosen to practice medicine in their individual

2:17

communities through the direct primary

2:19

care model. I'm your host, Marielle

2:22

Conception, family physician, DPC

2:24

owner, and former fee for service doctor.

2:27

I hope you enjoy today's episode and

2:29

come away feeling inspired about the future

2:32

of patient care, direct primary

2:34

care.

2:38

Direct specialty care is the opportunity

2:40

to make medicine yours, your style,

2:43

your terms, your relationships. I

2:46

am Dr. Begaris, and this is my direct specialty

2:48

care story.

2:54

Dr. Fred Bagares s a board-certified physician

2:57

in both sports medicine and rehabilitation

2:59

medicine. His clinical interests include

3:01

biomechanics, rehabilitation medicine,

3:04

pain science, spine care, electrodiagnostic

3:06

medicine, musculoskeletal ultrasound,

3:09

and medical education. After

3:11

medical school, he completed his residency in

3:13

physical medicine and rehabilitation, or PM&

3:15

R, at Northwestern University Rehabilitation

3:18

Institute of Chicago, in addition

3:20

to a fellowship in sports medicine. Dr.

3:23

Bagares believes that movement is the key

3:25

to living. He is fascinated

3:27

by how diseases affect the way people move,

3:29

which lead them to his care. Coming

3:32

from an osteopathic medicine background, the

3:34

transition to both PM& R and sports medicine

3:36

was very natural. He has worked

3:38

in a variety of settings, including a multi specialty

3:40

surgical private practice, academic

3:43

medicine, military medicine, and also

3:45

solo private practice. In his spare

3:47

time, he enjoys spending time with his amazing wife,

3:50

Chasing his two children and practicing jujitsu.

3:54

Welcome to the podcast, Dr. Begaris.

3:57

Thank you for having me.

3:58

Fellow Filipino doctor in the house, super

4:00

stoked. One of the things that I wanted

4:02

to open this podcast with is that

4:05

we have not heard the story of a physiatrist

4:07

before. So can you start us off

4:09

with what is PM& R and

4:11

what does it mean to be a physiatrist

4:13

absolutely. So PMR

4:15

is a fairly small specialty,

4:18

but it is the medical specialty that manages

4:20

conditions and disorders that affect the way

4:22

people move. Typically

4:24

as a result from chronic, congenital,

4:27

orthopedic, or neurological diseases.

4:30

So our, kind of our bread and butter

4:32

has been like stroke care, traumatic

4:35

brain injury, multiple sclerosis,

4:39

amputee care. But over time

4:41

it's evolved into these various

4:43

subspecialties. So pain medicine,

4:46

sports medicine, hospice palliative

4:48

care. Pediatric rehabilitation

4:51

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

4:55

we're pretty much covering all

4:57

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

4:59

in the Inpatient setting, doing acute

5:01

care rehab, a lot of them are outpatient

5:04

doing probably non surgical orthopedic

5:07

or, or pain medicine care. in

5:09

terms of the main difference between orthopedic surgery

5:11

obviously, the big obvious thing

5:13

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

5:15

lot of our care is really focused

5:18

on on different types of

5:20

injections. Some of us do EMGs.

5:22

A lot of it is, is looking at the overall

5:24

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

5:27

actually one of the big draws to

5:29

PMR. I was, I actually went into medical school

5:31

wanting to be an orthopedic surgeon. And

5:33

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

5:36

I kind of like looking at everything and that just

5:38

kind of fits my personality. But that's

5:40

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

5:42

think overall orthopedic surgeons obviously do surgery.

5:45

Physiatrists also tend to, to

5:47

follow people further, further in their

5:49

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

5:52

Now, with understanding what PM& R

5:54

is in relation to where it lives

5:56

in the medical specialty world, how it's not

5:59

orthopedics I wanted to ask

6:01

how your training was

6:04

to be able to to be

6:06

able to be a physiatrist in terms of

6:08

when you were in training, how what

6:10

kind of autonomy did you experience?

6:14

If any and how did that manifest?

6:16

Because with it being a smaller specialty,

6:19

I find sometimes that when people are like, Oh,

6:21

you want to do rural medicine? Like that

6:24

was my experience is like, create your own

6:26

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

6:28

about your training to be able to get

6:30

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

6:32

out on my own.

6:33

Right, right. My, my residency

6:36

was was amazing. I, I went to,

6:38

I did my residency with Northwestern,

6:41

formerly known as the Rehab Institute of Chicago.

6:44

And we had a pretty broad at

6:46

least back then, we had a pretty broad

6:48

scope of, of exposure. As

6:51

like, in terms of like the actual requirements,

6:54

inpatient versus outpatient versus

6:56

specialty rotations. I thought

6:58

we did a really good job, or

7:00

the program did a really good job of just You

7:02

know, laying it all out there. If anything

7:05

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

7:07

aren't the same. So, I definitely

7:10

ran across colleagues that had different experiences,

7:12

but I ended up the,

7:15

I ended up doing a fellowship after that.

7:17

I, I had a lot of training. I felt

7:19

really very comfortable as a general physiatrist.

7:22

So I, ironically, actually,

7:24

actually was planning on going into

7:26

kind of an inpatient. managing

7:29

spinal cord and neurological disorders

7:32

slash sports medicine, but there

7:34

wasn't like a real job for them at the

7:36

time. So I decided to go

7:38

to go on to fellowship to, to do

7:40

more in terms of learning sports medicine

7:42

and musculoskeletal injuries and electrodiagnostic.

7:45

But also more importantly I really wanted to

7:47

have interventional spine spine

7:50

skills. But overall,

7:52

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

7:54

vast I think you definitely

7:56

have to have an idea

7:59

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

8:01

heading, heading in, because there's just,

8:03

I was kind of the guy that, I

8:05

wanted to do inpatient. At one point I wanted to

8:08

do a spinal cord injury fellowship. I thought

8:10

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

8:12

over the place, which is as a resident was

8:14

great. Like. I was just excited about

8:16

everything. So, so I think

8:18

as a physicist, if you're interested in physiatry

8:21

or PM& R, you definitely have to be super

8:23

proactive because, again,

8:25

I'm 10 years out, so actually plus

8:28

10 plus years out. So I think the

8:30

options are probably, it might be almost too

8:32

many options at this point, but But I

8:34

think it's I think overall that that's

8:36

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

8:38

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

8:41

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

8:43

me to, to make this jump, nothing,

8:46

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

8:48

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

8:50

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

8:52

So,

8:53

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

8:55

next question is, did you see

8:57

any doctors who are doing cash

9:00

pay physiatry while in residency

9:02

or in medical school? And just because it is,

9:04

a very small subspecialty,

9:07

compared to family medicine

9:09

or, the number of residencies out there is

9:11

what I'm speaking to. But,

9:13

the answer is no. And that's not

9:15

surprising. I, I.

9:18

Hope again that this changes in the future,

9:20

given what you're sharing today. Now,

9:23

let me ask you about your geographic location

9:25

because you are in

9:27

Virginia Beach, Virginia. And I'm just

9:29

wondering about what drew you specifically

9:31

to that area. And do you find physiatry

9:34

is something that is crazily

9:36

needed in your area.

9:37

So, we were in Chicago

9:39

at the time and I actually wanted to,

9:42

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

9:45

a practice out in Vancouver,

9:47

Washington. Great practice,

9:49

multi specialty surgical group, but yeah

9:52

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

9:54

Is from Virginia Beach. I grew up in Northern

9:56

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

9:59

So I knew I wanted it.

10:01

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

10:03

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

10:06

we, we decided to move back eventually,

10:08

but it was actually kind of hard to,

10:10

to. to find a job in this

10:12

area, because I remember

10:15

distinctly when I was in fellowship looking

10:17

for jobs in this, in this locale,

10:19

just, just not exactly knowing

10:21

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

10:24

it was it was hard, it was hard to find

10:26

to get callbacks. And I think at the time,

10:28

the year prior to me graduating

10:31

was a really big hire year. And

10:33

so I think people were still,

10:35

no one was hiring the next year, so, so

10:38

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

10:40

on the, on the West coast

10:42

and my daughter

10:45

was like, like four or five years

10:47

old and she, all

10:49

of, all of the cousins are right around the same

10:51

age. So she started

10:53

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

10:56

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

10:58

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

11:00

man. You know how, I think

11:02

we got to move back. So like, I remember

11:04

I dropped her off at school and

11:07

I immediately started looking for jobs on the,

11:09

on the East coast. And it just

11:11

so happened that there was an academic position.

11:14

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

11:17

and just kind of went for it and got

11:19

the job offer and, and then

11:21

we ended up back on the East coast.

11:24

So let me ask you there because earlier, you

11:26

talked about how your residency was

11:28

amazing. You had so much exposure. You're

11:30

like, what do I not do in my practice

11:33

later on? And then you also talked about,

11:35

you're thinking specifically inpatient. When

11:37

shifted to, know,

11:40

the primary thing is that I need to be

11:42

close to family and I also need

11:44

a job. How did your narrowing

11:47

down of how you wanted to practice shift?

11:49

Like, did you? Just say like,

11:51

I'll be fine with whatever is open as

11:53

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

11:55

going to be in Virginia Beach.

11:57

Right. I really, my

12:00

priority at that time was to get my family

12:02

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

12:05

once I knew that, that's, that

12:07

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

12:09

to do it. And then in terms

12:12

of like, is this a job that

12:14

I, we could, I could take, quote

12:16

unquote it really kind of came down to the

12:18

finances, like I remember, I remember

12:20

like kind of crunching the numbers and I

12:22

was never released financially, literate

12:25

up until basically like, right afterwards,

12:27

right after fellowship when I actually started, Oh, I

12:30

actually have to pay attention now. So, when

12:33

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

12:35

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

12:37

to, to, to safely, go back

12:40

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

12:42

on and so forth. And so,

12:44

I guess it, it ever teach their own, like

12:46

just being home close, close to

12:48

parents was really, really important. And so

12:50

as long as I hit the number. Like,

12:53

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

12:55

I appreciate you answering that because

12:58

many people in medicine

13:00

when, they're with a

13:02

particular amount of loans after if

13:05

they're not going to a loan repayment program

13:07

because they're driven to move close

13:10

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

13:12

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

13:14

Like guaranteed loan repayment and you're having

13:16

to repay with what you're making. I

13:18

think that's a very excellent thing for people

13:20

to hear in terms of your perspective on how you went

13:22

through choosing your

13:24

first job there. Because I will say knowing that

13:27

there is other jobs that came after. So,

13:29

In terms of this idea of

13:31

taking a, a, an employment

13:34

position that was like fitting certain needs,

13:36

but then as long as it met a certain number you

13:38

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

13:40

like put food on the table. You also

13:43

then became a contractor with the Navy

13:45

as well as you then

13:47

had another employment position with an MSO.

13:50

Did You continue to

13:52

take positions with the,

13:55

with those requirements in place,

13:57

or did your requirements change as

13:59

you went on to those other positions?

14:02

Overall, I, the requirement that really changed

14:04

was, honestly, just a circumstance

14:07

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

14:09

the job I came back for was an academic

14:12

position, which was great, but then it

14:14

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

14:16

So I, but I signed

14:19

a non compete is a two year

14:21

non compete. And because I'm

14:23

in Virginia Beach, There's only really,

14:25

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

14:28

right? So, so, at that

14:30

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

14:33

or I could also start,

14:35

looking at the military as a way. And

14:38

Virginia beach or the Hampton Roads area is a big

14:40

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

14:42

military but they, they have,

14:44

some military opportunities and I just

14:47

happened to apply for it. So that's

14:49

that was definitely actually just

14:52

great luck. Because that's actually

14:54

when I, when I, as I was exiting

14:57

the, the, the second

14:59

job and about to go into the,

15:01

the contractor position, That's

15:03

actually start when I started to think about like,

15:06

how else does this model work?

15:08

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

15:11

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

15:13

then once I actually got into the,

15:16

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

15:18

a sports medicine physician. Is

15:20

it interesting? If anyone's interested in these kinds

15:22

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

15:24

that all

16:14

my patients were like, 20

16:16

years old, knee pain, shoulder pain.

16:18

I had an ultrasound machine. The

16:20

trick was that I worked four days a week,

16:23

which was great. But my, I work from

16:25

5am to 3pm. So

16:28

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

16:30

home for the kids and stuff like that. But

16:33

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

16:35

meant I was leaving at like 415. But

16:37

it's, I really, I

16:39

really, really enjoyed it. So I don't

16:41

think my, my focus had really

16:44

changed. If anything, I got a

16:46

little bit more focused because during that

16:48

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

16:50

sure if I was going to stay as a contractor.

16:52

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

16:54

this. Versus should I branch

16:57

back out? There's definitely pros and cons

16:59

in the military system, like, like anything

17:01

else. But I think it was

17:03

actually a very important part of my,

17:05

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

17:08

hearing about your non compete that you had with your

17:10

former employer was there any issue

17:13

with you practicing wherever you wanted to

17:15

because you had a contractor

17:17

agreement?

17:19

Then, one of the stipulations was that,

17:21

like, they could, that the

17:23

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

17:25

the government, so that, that, that

17:27

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

17:29

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

17:31

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

17:33

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

17:36

at the, at the, at the military

17:39

facilities of, of other docs

17:41

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

17:43

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

17:45

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

17:47

are you in for because we all do, we

17:49

all sign non competes, but so

17:51

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

17:53

other option would be to, write

17:55

it out or move out of the area.

17:57

So.

17:59

It's it, I know that there are listeners

18:01

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

18:03

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

18:05

to the podcast content, there are doctors

18:08

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

18:10

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

18:12

California where non competes are unenforceable.

18:15

I hope that becomes nationwide because it's

18:17

ridiculous that because someone says you can't

18:19

practice here. There goes your doctor.

18:21

Like, there goes the expertise out of the area.

18:24

So, definitely something to consider, especially

18:26

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

18:29

looking to work with an employer, take

18:31

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

18:34

make the decision based on whether someone

18:36

can take the non compete out or not. So

18:39

let me ask you there because you were

18:42

hearing again, this like, Oh my

18:44

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

18:46

And then going to an academic position,

18:48

you had another position, you went to, to be

18:50

a contractor. Did you find

18:52

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

18:55

journey that you're like, but I

18:57

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

18:59

did the the, avatar

19:02

patient that you just, that you just described,

19:04

was that not enough for you? Did that have any

19:07

play in why you moved on from being a contractor?

19:11

Definitely. So, while it was

19:13

great, I was doing a lot of musculoskeletal

19:15

stuff. I wasn't able to do,

19:17

I wasn't doing any injections for the spine

19:20

anymore, and I wasn't doing EMGs.

19:22

And I had actually tried to make

19:25

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

19:27

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

19:29

logistically, like, it would

19:32

be too, I would be, not completing

19:34

my primary job in order to fill these

19:36

other holes. So, I,

19:38

at that point, I had stopped doing

19:42

spine injections and EMGs for almost

19:45

two and a half years. And Being

19:47

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

19:49

skills aside from just, I liked

19:51

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

19:53

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

19:56

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

19:58

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

20:00

out and try and do this again. But

20:02

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

20:04

time that I started looking

20:06

at telemedicine. So,

20:09

one of the, one of the, I

20:11

guess the, my non compete never mentioned

20:14

anything about telemedicine. So,

20:17

and this is like prior pre COVID, so

20:19

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

20:21

learning about DPC was like,

20:24

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

20:26

telemedicine back then was like,

20:28

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

20:30

their primary mode of practice, at least not,

20:32

not to my knowledge, so I, went

20:35

on the Facebook groups and, I look back

20:37

at my old posts from back then, so

20:39

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

20:41

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

20:43

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

20:45

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

20:48

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

20:51

gray, like, so, I started

20:53

to kind of approach that, but as

20:55

an orthopedist, someone who supports medicine,

20:57

it was like, even more like, How

20:59

does that even work? Right? So

21:02

I what I ended up doing

21:04

was my plan was to

21:07

to start off as a telemedicine practice

21:09

just to kind of dip my toe in the water and

21:11

see how it would build. And it was a cash

21:13

based model. So, at that time, insurance

21:16

wasn't paying for, telemedicine visits.

21:19

So, working you

21:21

know, from 5am to 3pm,

21:23

it gave me some time to like to

21:25

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

21:28

So, I was hoping that okay, I got plan

21:31

A is I just stay with the military plan

21:33

B is that I build up this this telemedicine

21:35

practice and if I decide to go out

21:38

Then I, I could use that telemedicine

21:41

business to funnel a brick and mortar practice.

21:44

So, I, I created

21:47

a model, I had the EMR, I had all

21:49

everything set up. I had some patients coming

21:51

through. And then I had

21:54

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

21:56

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

21:59

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

22:01

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

22:03

it lightly, like that makes no sense.

22:05

Like, how can you treat people? Without

22:08

actually seeing them and I understand

22:10

their point, but at the same

22:12

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

22:15

So I was just about to make the jump and

22:17

then COVID happened,

22:20

right? And so I,

22:22

in my, so

22:25

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

22:27

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

22:30

like, and I just laughed. I

22:32

just kind of was like, wow. It's

22:34

like in one move, it completely tanked my model

22:36

because the two things that ever had to happen.

22:39

Number one is that insurance

22:41

would now start to take or pay for telemedicine

22:43

visits and number two, there

22:46

would be no access to in person visits. The

22:49

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

22:51

Oh my gosh. So then I got a flood

22:53

of calls, people like, Hey, do

22:55

you, wanting to see me telemedicine wise?

22:58

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

23:00

to do I take insurance.

23:03

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

23:05

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

23:07

And so everyone was like,

23:09

well, maybe you can start to recredential. Because

23:11

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

23:13

lapsed. So I was like, maybe

23:16

I could recredential and. Again,

23:18

COVID, like people were not working. So the processing

23:21

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

23:23

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

23:25

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

23:27

it, it actually gave me the opportunity

23:30

to, to build an LLC. So,

23:33

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

23:35

from a, from a business owner standpoint. So.

23:38

Let me ask you there, just stepping back into the

23:40

telemedicine experience that you crafted.

23:42

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

23:44

you had everything crafted, people were coming in. I

23:47

want to ask about, what what types

23:49

of patients were coming to the practice

23:52

and what were you doing to prove

23:54

all those naysayers wrong with what you had built?

23:57

Right. So, a lot

23:59

of them were, were people that

24:02

I think actually the patients were looking for

24:04

something different, that was number one. A

24:06

lot of the people that I saw were, were

24:08

actually Already doing

24:11

all the conservative management stuff, meaning

24:13

like they, I would get referrals

24:15

from people who just completed physical therapy

24:17

or had done everything and a

24:19

lot, a lot of the, the

24:21

people also just wanted someone to put the

24:24

pieces together. I think that that's what,

24:26

that's actually my, my main strength

24:28

is that as you, as Someone goes to

24:30

with an orthopedic or neurological problem,

24:33

they get an MRI, they'll get an orthopedic

24:35

surgeon consult, they're going to neurosurgeons consult,

24:37

they'll get a million injections. And

24:39

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

24:41

back together. So a

24:43

lot of my patients at that time were kind of of

24:45

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

24:47

spring, I was seeing

24:50

people that had like, You

24:52

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

24:54

seen, this many people. What do you

24:56

think? So it was, it was more

24:58

of like a consult people wanting

25:00

a second opinion more than, people

25:02

wanting like acute care. Like, obviously

25:05

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

25:07

that. But it was, that's

25:09

when I really started to realize that, patients

25:12

were really not really happy

25:14

with, What was available and

25:16

they really just wanted someone to put things

25:18

back together in terms of like

25:21

I mean I would literally have to have patients come to

25:23

me and say like I've had all these

25:25

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

25:27

like? And I just need you to

25:29

just explain what this all means.

25:32

And with telemedicine and

25:34

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

25:36

I really enjoyed that piece of it, so,

25:39

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

25:41

drove that piece.

25:42

When you had this telemedicine practice set

25:44

up, did you offer one off consults

25:47

as well as memberships or did you have mostly

25:49

one off cash pay consults?

25:51

It was really just, it was mainly just

25:53

one off type visits. And I'm

25:55

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

25:58

it's interesting because like, I

26:00

was playing around with the membership model back then,

26:03

because at the time, there was no, there was

26:05

no PMNR model. Number two,

26:08

all of the direct care models were

26:10

TPCs, which is, a large majority

26:12

of membership bases. Like, how do I, how

26:14

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

26:17

Someone dealing with like an

26:19

acute meniscus tear, the,

26:22

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

26:24

it doesn't make sense to see them chronically

26:27

Or month and charge them a monthly fee.

26:30

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

26:32

then there are some people that have you know, chronic

26:34

osteoarthritis, rheumatoid arthritis, they

26:37

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

26:40

So then I was like, I'm a sports

26:42

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

26:44

should I be marketing to? So it turns

26:47

out that I, I'm still right

26:49

now, I'm doing kind of a, a

26:51

one off visit kind of a, still kind

26:53

of a fee for service type of model. But

26:56

I'm still playing around with it at the same

26:58

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

27:01

Kind of wants but but

27:03

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

27:06

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

27:08

way that I have seen that

27:11

I kind of played around with is

27:13

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

27:16

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

27:19

I, as a specialist, you have to be

27:21

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

27:23

people in my space are doing. Regenerative

27:26

medicine wellness

27:28

they're offering something extra. And

27:30

while I do injections and I do procedures,

27:33

it's really very, it's

27:35

kind of against my general style.

27:37

I don't like to do injections over

27:40

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

27:42

people get better. So

27:44

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

27:47

because I have to give them something, and

27:49

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

27:51

wellness space or the functional medicine space,

27:53

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

27:55

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

27:58

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

28:00

to make it worthwhile? And, I,

28:02

I'm not really quite yet sure what direction

28:04

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

28:06

that it is going in terms of just like a

28:08

straight fee for service, but but

28:10

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

28:13

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

28:15

of how to deliver care.

28:17

Amazing. And as it should be, right? Because

28:19

you're thinking about how can I deliver

28:22

care to my patients, not what is the

28:24

next code that will be covering my services.

28:26

So love it. Love it. Now

28:29

one more question on the telemedicine

28:31

portion because when

28:34

you talk about, having the time even

28:36

when you were in your contracting position to

28:38

like Find information on your patients

28:40

to give them an amazing consult.

28:43

That's a big challenge in DPC,

28:45

direct specialty care. When you're independent

28:48

and the local hospital,

28:51

EMR, medical records department won't

28:53

pay, won't play friendly with you. Do

28:55

you have any tips and tricks on getting information

28:57

so that you can have, a very deep dive

29:00

into a person's physical health

29:02

before they come and see you.

29:04

At least in my area, I rarely

29:07

went into the Epic care link. I

29:09

try to get community access as much as possible.

29:11

Cause as we all know, like, notes

29:14

and imaging studies, they somehow find in

29:16

their way into into other charts. So,

29:19

I got access to all the local imaging

29:21

centers as well. And, Virginia Beach

29:23

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

29:25

like three or four places to check. So

29:28

like I have access to the local hospitals,

29:30

but then also some of the local universities,

29:32

UVA, VCU, ECU,

29:34

Duke University, even Mayo.

29:37

I have access there. And for,

29:39

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

29:42

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

29:44

terms of, like, talking

29:46

with actual practices, it, it

29:48

is very, very difficult, I'm

29:50

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

29:53

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

29:55

be a micropractice, and my, my wife

29:57

is the one that's helping with all the

29:59

back end stuff, and she's not from,

30:02

she's not from the healthcare background,

30:04

so. It's very interesting. She's

30:06

more from the business business world. And she's

30:08

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

30:10

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

30:12

patient that are referred to a specialist

30:14

and the fax machine we

30:17

You know, we, we faxed a

30:19

request and did, did, did

30:22

they get it? Did the fax machine at paper,

30:24

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

30:26

thing I can say is that I think you really

30:28

just have to have a dedicated person

30:30

diligent. And fortunately for

30:32

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

30:34

practice, which is the way that I want it that

30:37

I think that following up on that stuff

30:39

isn't, isn't too onerous.

30:40

I'm sure there's people just like shaking

30:42

their heads at what you're saying. I

30:45

know that I have this conversation frequently

30:47

about how patients, when they go

30:49

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

30:51

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

30:54

and then, I absolutely get the whole

30:56

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

30:58

that you sent over that you claim you faxed over.

31:01

And then so now we save

31:03

our documents and our faxes that we

31:05

send to the patient's chart where they can literally

31:07

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

31:09

had less barriers to also get our patients

31:12

their studies that they need for their specialty visits

31:15

because they can pull them up on their phones. And

31:17

I love, the descriptions of like, Yeah,

31:20

the doctor was like trying to skirt past

31:22

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

31:24

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

31:27

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

31:29

Yay. So yeah, love it. Now

31:31

tell me about your transition from

31:34

your your opening your own LLC,

31:36

having a telemedicine having a telemedicine

31:39

practice, and then going into

31:41

an MSO after that. So, what

31:43

was the, I know you mentioned

31:45

COVID, was that the main driver to

31:48

that led to the MSO?

31:49

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

31:52

there was there was some safety in staying

31:54

in the military. Because it

31:56

was a contract. It was a contract. So

31:58

it's like guaranteed pay and so on and so

32:01

forth. But I

32:03

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

32:05

really established myself in this area,

32:07

meaning like I got into this area in 2016.

32:11

I practiced for two years at an academic center

32:13

and then disappeared for another two years. So

32:16

it's like, people, just talking with

32:18

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

32:20

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

32:22

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

32:24

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

32:26

was always this, awkward conversation.

32:28

So, but I, I really wanted

32:30

to kind of see medicine

32:33

the way that I wanted it to be done. And

32:35

even when in my very first

32:37

job, I was like, I always had these

32:40

ideas of how rehab and

32:42

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

32:44

this is an opportunity where I can

32:46

actually do something in

32:48

person, with every, it's basically

32:51

I can control everything. And

32:53

I just wanted to see how it would go. And

32:56

it was, from a practice standpoint,

32:58

it was, I was full, I'm,

33:01

I had all the types of patients

33:03

that I wanted to see. But

33:06

at the same time, like an insurance based model,

33:08

like I found myself just not

33:10

being able to spend enough time with the patients. And

33:13

I, I fortunately never let

33:16

myself head into like that

33:18

30 to 40 patient range, but I,

33:20

even still I was still seeing people like 20

33:23

to 20 to 25, which is still a lot.

33:26

And, I, I just started to

33:28

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

33:30

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

33:32

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

33:34

And I think it was actually

33:36

burning out and, and I didn't realize

33:39

it. And, or I was burning out and

33:41

I didn't realize it. And so

33:44

the thing that really kind of like triggered me was

33:46

that like, there was just like

33:49

the billing, like I was doing all this hard

33:51

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

33:53

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

33:55

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

33:57

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

34:00

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

34:02

to maybe get money, or the

34:04

fact that like the billing claims

34:07

ring managed by people who were not motivated,

34:09

there was no incentive for them. So

34:12

it really kind of like, got

34:14

me thinking like, is this what

35:13

it is? This is, this is what my life is.

35:15

And I had this like,

35:17

Long time ago, I set this timer on

35:20

my, on my phone of

35:22

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

35:24

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

35:26

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

35:29

the fire movement, like retiring early, things

35:31

like that. So I'd set a date

35:33

for my son's 18th, when he

35:35

graduates high school, basically. And I was like,

35:38

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

35:40

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

35:42

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

35:44

found myself looking at that clock more

35:47

like every day. I remember looking at

35:49

the, at, at, at that timer

35:52

and then going to work. And then I

35:54

was like, man, this is not,

35:56

this is not good. And it

35:58

just, I brought up concerns and

36:00

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

36:02

anymore. And I.

36:05

I essentially kind

36:08

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

36:10

Just, I just quit at

36:12

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

36:14

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

36:18

and I was like

36:20

looking through the, my phones,

36:22

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

36:24

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

36:27

pictures over the years, and

36:29

I just noticed that my face, like I

36:31

was, I stopped smiling. Like I

36:33

just saw myself change and then like.

36:36

My, my daughter actually,

36:38

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

36:40

she was like maybe 11 or 12, she

36:43

said, or she was 12 and

36:45

she was just like asking me, are you okay?

36:47

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

36:49

wrong. And, but apparently like every battle, everybody

36:52

else could see it except for me. And

36:54

then. I was literally on the boat

36:57

looking over and I just was like, I'm

36:59

done. I can't do this because I

37:01

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

37:03

or, or I find a different job

37:05

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

37:07

to do anymore.

37:09

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

37:11

an even worse non compete, equivalent.

37:14

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

37:16

in leaving medicine sucks

37:19

for all of us who have gone to medical school and

37:21

have invested our, mostly our twenties in,

37:23

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

37:26

Christmas party. I need to study

37:28

for my board exams. So I'm so glad

37:30

you did not quit medicine. Because

37:32

you already had your LLC, because

37:35

you had already, dipped your toes into

37:37

a cash based practice, what

37:39

was the transition period like between

37:42

opening up your practice as it

37:44

stands now and your former job?

37:47

So two months, so,

37:50

I literally, as soon as I came back

37:53

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

37:55

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

37:58

So my last official day was

38:01

October 31st of 2023.

38:04

And I opened up November 1st. But

38:07

I, I think I was just mentally

38:09

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

38:11

like this kind of idea journal.

38:14

And I started going, from when I

38:16

created the telemedicine business and I started,

38:18

I date everything and I write everything and, every crazy

38:20

idea that I have, I write it down. And

38:23

I went back to 2016.

38:25

And so I had, I had to actually

38:28

have these ideas for a long time. And. I

38:30

kept rewriting the same idea over and

38:32

over and over 2017, 2018.

38:34

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

38:37

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

38:39

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

38:41

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

38:44

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

38:46

a place and, This and that, like

38:48

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

38:50

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

38:52

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

38:55

I, I think two, two months

38:58

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

39:00

about it. But at the same time,

39:02

like I had thought about it for such

39:04

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

39:06

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

39:09

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

39:12

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

39:14

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

39:16

kind of a hard pill to swallow, but I

39:18

tell you, the, the one thing, and maybe

39:20

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

39:23

it happen is like, I had to find ways to

39:25

make it real for myself. And

39:27

the one thing that I did was I bought a website

39:29

with my name on it, and that's when

39:32

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

39:34

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

39:36

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

39:38

I was like, well, like you

39:40

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

39:43

two months, short answer, two months.

39:45

Super powerful. And, I that's

39:47

definitely something that physicians have used

39:50

in different specialties in terms of the transition

39:53

to another practice of their own,

39:55

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

39:58

that is your own and that transitions

40:00

later on to your website.

40:02

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

40:04

have Dr. Fred Beguiris Dr. Haley Miller

40:06

had her website just featuring her as

40:08

a doctor. So she was an individual, not

40:11

part of the system anymore before opening Montana

40:13

State Diabetes. So I absolutely

40:15

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

40:17

people to take to think about when,

40:19

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

40:21

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

40:23

to pull that trigger yet. You can absolutely

40:26

do things like this that empower you. And like

40:28

you said, like, you're motivating

40:30

yourself to make this thing real, because

40:33

this is not a magical unicorn type of practice.

40:35

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

40:38

So love that. Now, let me ask

40:40

you, because you had done again,

40:42

this, like dipping your toes into cash based

40:44

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

40:46

this is what I'm doing. In

40:49

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

40:51

doctors and specialty doctors as well.

40:54

How did you ask, like, what

40:56

was your mindset in terms of how

40:59

you asked questions about, what,

41:01

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

41:03

how would you incorporate what they're doing

41:06

strategically into your practice or not

41:09

based on, you not only

41:11

having these journal entries from 2016,

41:13

just like thinking about this over and over, but actively

41:16

like shifting your mindset to, no,

41:18

I'm doing things to make this real.

41:21

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

41:24

like I talked to the couple of the, the drug

41:26

primary care docs in the area and just

41:28

trying to figure out like, what

41:30

do their patients, what does, what

41:32

do their practice needs and like, is

41:35

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

41:37

And. I I

41:39

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

41:41

I was I was hoping for in the sense of

41:43

like Oh, this is what I can do Because

41:47

especially as a specialist I I think

41:49

one of the main challenges is that most people

41:51

will look at me and say like well

41:54

I need an injection for my knee like I can

41:56

go and get that or from

41:58

my you know insurance my in network physician

42:02

And I had to really

42:04

change my mind in terms of saying like,

42:06

you know what? They're trying to equate

42:09

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

42:11

that. So then I started

42:13

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

42:15

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

42:17

is your practice? Like, who are,

42:19

what, what can you offer? And

42:21

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

42:23

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

42:25

to not to get too, philosophically you really have

42:27

to understand like who you are and what you

42:29

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

42:32

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

42:34

of DPC docs, and I've always like

42:37

kind of wanted to talk to them about, what

42:39

was their motivation. And, even

42:41

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

42:44

don't really know what it is that makes

42:46

me different or makes me special. I

42:48

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

42:51

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

42:53

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

42:55

I figure things out, but I'm,

42:57

I'm the product. And I think

43:00

trying to, to. change

43:02

the mindset of how to

43:05

for you to appreciate how valuable you are

43:08

to the community and what you can offer patients.

43:10

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

43:12

have heard that someone say something that might have resonated

43:15

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

43:17

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

43:19

like, rough days, man. I

43:21

was like, why are you doing this? And

43:23

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

43:26

do other things, to come back and

43:28

to this and do that. And, but

43:30

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

43:32

just really value yourself as a physician,

43:35

as a person in general, it's

43:37

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

43:39

have to stop and do and. I

43:41

think when you're trying to market yourself and

43:43

sell your practice, that's a hundred

43:45

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

43:48

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

43:50

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

43:52

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

43:54

I just kind of move on. So I

43:56

think really just valuing myself is

43:58

to answer your question was the mindset shift.

44:01

So, pause, rewind that about

44:03

15 seconds and replay that over

44:05

and over and over again. Because absolutely,

44:07

I mean, it is, it is a vital

44:09

part of what we are doing in direct

44:11

primary care and how we preserve our autonomy

44:14

and how we write our copy on our website

44:16

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

44:18

When you know that you are valuable, even

44:21

though the former employer said, we're going

44:24

to a non physician model. Or,

44:26

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

44:28

million patients per hour so

44:30

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

44:33

per code. Whatever it is that makes

44:35

one feel devalued as a physician in

44:37

the, regular fee for service system, stop,

44:40

rewind now 20 seconds and

44:42

listen Bagheera again, because

44:44

that is so imperative for what we are doing

44:47

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

44:50

So, love it. Absolutely. Love it. Let

44:52

me ask you then because you, we're

44:54

saying like done. I'm doing it. I

44:56

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

44:59

want to ask about the challenges and

45:01

opportunities being a physiatrist

45:03

with a space because I hear

45:05

people and I know you have as well

45:08

of like, Oh, I can't afford an

45:10

ultrasound to start off with or like, I

45:12

and you talked about the marketing piece and like who

45:14

was joining your telemedicine practice, but in

45:17

terms of as you continued

45:19

on and had the space

45:21

to then build out to make it fit

45:23

what you wanted to bring to your community, how

45:26

did that manifest in challenges and opportunities

45:29

specifically with physiatry care and

45:31

orthopedic health services?

45:33

So you know, fortunately

45:36

for me, I, the, I

45:38

had three main pieces of

45:40

equipment that I use. So an EMG machine,

45:43

an ultrasound machine and

45:45

a fluoroscope and

45:47

the fluoroscope I'd never owned, but I did

45:49

own the EMG and the, and the ultrasound.

45:52

So as I was exiting,

45:54

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

45:56

difference. And, and, and then it,

45:58

because it was purchased through my, my

46:01

previous employer and I just purchased it

46:03

from them. So I just

46:05

knew I had to have that. But then it came

46:07

up to like, well. to do at

46:10

to do injections of the spine,

46:12

do I want to buy a

46:56

new machine? And aside

46:58

from the cost, the build out, these things can

47:00

be like between 80, 80 to 100, 000.

47:02

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

47:05

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

47:07

extra staff. And it just, it gets bigger

47:09

and bigger and bigger. So

47:11

right now, I, I did

47:13

find a place, I'm some renting space out

47:15

of a an internal medicine, doctor's

47:18

office, I have one room. With

47:21

both machines but I'm not doing injections

47:23

for the spine anymore right now. So,

47:26

I, I was previously doing it at a surgery

47:28

center and that's still a potential option

47:30

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

47:33

participate with, with commercial insurances

47:35

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

47:38

workers comp patients. So, that,

47:40

that might be an avenue, but at the same

47:42

time, like, I, again, I,

47:44

I think I really just kind of came down

47:46

to what my, I feel

47:48

my role is. is to

47:51

to help people put pieces together like

47:53

the injections were great, but I realized

47:56

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

47:58

thing, in my opinion, like it's really

48:00

interpreting the injection being there for patients,

48:03

making them feel you know, that they

48:05

have some control over what what has actually happened.

48:07

So, in terms of like the

48:09

challenges, it's, like, I have

48:12

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

48:14

nothing's really been challenging from that standpoint.

48:17

Fortunately, the equipment that I did purchase

48:19

wasn't super expensive but again,

48:21

I had already kind of planned for it. So if

48:23

anything, I just, made sure that when I paid

48:25

off, I could get, I, I could do, use, use

48:28

a credit card to get points because I love points,

48:30

points, points throughout my travel. So that

48:32

was, that was kind of how I just figured out that piece.

48:35

And then I just kind of paid it off, like, just like a here

48:37

and there, but But I'm, I'm not really looking

48:39

to expand just yet or

48:41

if ever, because it's just a room, most of my

48:43

visits like yours are like, 60 to 90 minutes.

48:46

I was like, well, I don't need two or three rooms anymore

48:48

to go run, from room to room. But

48:51

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

48:54

Fantastic. And let me ask you about the

48:56

using the space in the internal medicine, internal

48:58

medicine physician's office. Was that like,

49:01

Hey, I'm asking around for people

49:03

are asking around if people have space.

49:05

Was that like a, Facebook marketplace

49:08

listing like Jenna Silikowski and her

49:10

buying her DPC off Facebook? How did

49:12

that manifest?

49:13

So, It my, my,

49:16

the person I'm renting space from

49:18

was actually my physician was my own personal,

49:21

like, internal medicine doc, and they,

49:23

they are solar practice, but

49:25

they're also still in the commercial

49:28

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

49:30

basically if you hear, I just. if

49:32

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

49:34

knew. And so I just

49:36

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

49:39

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

49:41

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

49:43

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

49:45

really look like online or anything

49:47

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

49:49

said, Do you have space? And and everyone

49:51

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

49:53

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

49:56

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

49:59

are you like, was that an

50:01

easy negotiation? Do you have a particular

50:03

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

50:05

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

50:07

Right.

50:08

Right now I'm going month to month so

50:10

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

50:13

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

50:15

than happy because he was, he wasn't

50:17

even using the room. So, I'm

50:19

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

50:21

working out. Like, I don't really think

50:23

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

50:25

point. So.

50:27

And this question is coming from, like, I,

50:30

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

50:32

entrance space for patients of

50:34

the practice your practice, as well as this internal

50:37

medicine physicians. Yeah. Yeah.

50:40

Go ahead.

50:41

Yeah. No, it's the space actually works

50:43

out because it is a medical building. So

50:46

on the same floor is a

50:48

physical therapy clinic and an orthopedic

50:50

surgeon and primary

50:52

care as well. But

50:55

so it's, from traffic

50:57

wise, it's good, people picking up stuff

50:59

and seeing, seeing my practice my signs

51:01

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

51:04

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

51:06

happened and I hope it has, but the person

51:08

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

51:10

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

51:12

Dr. Begaris's patients keep moving

51:14

and moving and moving and I'm still

51:16

sitting here parked in the parking lot, waiting

51:19

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

51:21

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

51:23

you do get that, Hey, what,

51:25

what is, what else is in this amazing medical

51:27

building? Awesome. Yeah. Let me ask

51:29

you now about your journey in opting

51:32

out of Medicare because that is a big challenge,

51:34

especially for specialists like Dr. Grace

51:36

Torres. Another fellow Filipino doctor,

51:38

but she talked about how in

51:40

podiatry, most of her patients were going

51:42

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

51:45

I let them go, I made space for people

51:47

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

51:49

So what was your journey like opting

51:51

out of Medicare? And did you ever have any hesitation

51:54

to opt out or not?

51:56

So I did opt out of Medicare

51:58

I started that process about

52:01

like, it's interesting because like,

52:04

I wasn't sure how it would happen. Because

52:06

when I quit, or I put in

52:08

my notice about two months prior to me actually leaving.

52:11

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

52:13

out now. But I didn't want to

52:15

like, throw out flags at the same time,

52:17

so, it caused problems like

52:20

towards the end. So I, I actually chose

52:22

about two weeks prior to me leaving. And

52:25

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

52:27

kind of anticlimactic because it's literally just

52:29

a form and I was expecting something, I

52:31

don't know, something bigger. And

52:34

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

52:36

actually get off, get approved. And so

52:39

it took about two months,

52:42

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

52:44

six to seven weeks before I actually. figured

52:48

it out. And I never got him.

52:50

I never got a letter. I never got anything

52:52

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

52:56

using the opt out tool to figure it out. But

52:59

in terms of the decision, it was easy.

53:01

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

53:04

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

53:07

just too easy to get sucked back

53:09

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

53:12

do run into some problems a little bit because

53:14

I'm trying to figure out, in terms of

53:16

like working, partnering with other practices

53:18

and offering my services

53:20

as a 1099.

53:23

And still the same issue is that,

53:25

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

53:28

credentialed through them. And I was like,

53:30

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

53:32

just gonna, I mean, from obviously

53:35

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

53:38

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

53:40

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

53:42

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

53:44

So, so it was, so mentally

53:46

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

53:48

the posts. I, I, I

53:50

won't be able to do locum's

53:52

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

53:54

but I I'm done. Like,

53:56

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

53:59

My two happiest jobs prior to

54:01

being a physician was selling shoes at Foot Locker

54:04

and working at the airport, escorting

54:06

people by wheelchair.

54:09

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

54:11

so much happier. So

54:14

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

54:17

love it. And I'm sure that if people

54:19

stop and think that they would find,

54:21

other jobs, like I used to teach summer camp

54:23

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

54:26

asking someone if they wear their seatbelt during a Medicare

54:28

physical wellness visit. No, thank

54:30

you. I would absolutely take, scissors

54:32

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

54:35

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

54:37

is something that I was like, Oh my gosh,

54:39

when we set up your interview I

54:41

had, just doing research for this interview. I

54:44

was like, how is how is that

54:46

that your former employer has

54:48

an announcement about you leaving the

54:50

practice on their page? Like that was something that

54:52

threw me for a loop. So can you tell the

54:54

audience about what what happened?

54:56

What transpired there? And has it affected

54:59

your practice in a good or bad way at all?

55:02

So, yeah, I mean, the big

55:04

thing I noticed, You

55:06

know quickly right after is that the

55:09

the internet google searching your name is

55:11

a big is huge and

55:14

so I wrote a letter to

55:17

just my departure letter to patients and

55:20

prior to me leaving and

55:22

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

55:24

kind of just from that standpoint. And

55:27

then I noticed like six weeks later that

55:30

after I'd left the practice that they now

55:32

posted it online and I was like, well,

55:35

why, why post that now? The,

55:38

but what it did do is it actually bumped my,

55:40

my ranking down. So it's not the

55:42

first thing. And so, I

55:44

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

55:46

did that then on a, because

55:49

I was really pushing for them to do it

55:51

way before I actually left. And

55:54

that was a struggle on a different conversation,

55:56

but so, but it didn't

55:58

really affect, it didn't really affect me

56:00

if, if, At least that I can tell,

56:03

but I, there's

56:05

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

56:07

really kind of confused because I had already

56:09

been gone for six weeks. So why post it

56:11

now? But at the end of the

56:13

day, press is press, my name still pops up

56:15

and my, my, my other two websites

56:18

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

56:20

hasn't really bothered me.

56:21

Now with your practice MSK Direct, I'm

56:24

super excited to start asking these questions about the

56:26

details of your practice because there was a PMNR

56:29

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

56:31

I had met him at the Take Medicine Back conference

56:34

early in February, and he was like, I

56:36

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

56:38

hands are doing What is Mr.

56:41

Mr. Mr. Burns, like, fingers

56:44

when, when people say these things to me, but

56:47

for you when you opened up

56:49

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

56:51

my fluoro today, might be coming

56:53

down in the future. Did your

56:55

services start off with like

56:57

a set number of services? And then

56:59

have you expanded from there? Or

57:01

have you listed everything you do to see

57:04

what sticks?

57:06

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

57:08

set number of services. And

57:11

for the most part, I, it's really

57:13

the, the patients that have actually been seeing me

57:15

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

57:17

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

57:20

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

57:23

most of my care, like, again,

57:25

is like, is really just trying

57:28

to be a good doctor and trying to

57:30

figure things out for people. But

57:33

again, it's, I think that people

57:35

are kind of maybe selecting me for that reason

57:37

and I think my website kind of goes in like

57:39

you read my general approach and even on

57:41

my, on my, my Instagram, I have

57:43

a certain style of practice

57:46

and I mean, injections are great procedures are

57:48

great, but. There's no shortage

57:50

of people doing procedures, at

57:52

least in, in, in my specialty,

57:54

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

57:57

a place for people to help actually putting, put

57:59

things back together and explain what exactly

58:01

what happens because I think.

58:04

A lot of people perceive these procedures

58:06

that we do as like the end all be all,

58:08

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

58:10

does the procedure mean to you?

58:12

What does it allow you to do? Does this,

58:15

does this injection allow you to sleep

58:17

better? Get off of medications?

58:20

Are you, are you going to move more? So

58:22

I haven't really, really pushed

58:25

doing more procedures, because to me, procedures

58:28

aren't, aren't what is missing from

58:30

the, from the community. It's people

58:32

who actually understand rehab and,

58:34

and how pain works and,

58:36

and looking at the natural history of chronic

58:39

musculoskeletal disorders. Like there's

58:41

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

58:44

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

58:46

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

58:48

right now, I'm the best. Come see

58:50

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

58:53

so like I said, the services isn't,

58:55

isn't my, isn't my cell.

58:57

It's me.

58:58

And I think about how, at least

59:00

we were taught at Creighton 80 percent

59:03

of what you need is coming from the history

59:05

and not the, 20 percent

59:07

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

59:09

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

59:12

this is why going to doctor school matters because

59:14

we've had the training in an hours,

59:16

thousands of hours, more than a non physician

59:19

provider to be able to think. And

59:21

then that is a, that allows us

59:23

to then, especially after you realize

59:25

that you are valuable. Be able to talk with

59:27

your patients with the time you need to be

59:29

able to share exactly what is

59:32

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

59:34

and how to explain that in plain English rather

59:36

than medicalese. So I absolutely love

59:38

that. That's what your value proposition is,

59:41

that that is the value

59:43

proposition that you find your patients are loving. So

59:46

let me ask you here about. Your

59:48

website. When you have your services

59:50

listed and there's a contact form, what

59:53

does it look like after someone says like, Oh,

59:55

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

59:57

more. Do you have a meet

59:59

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

1:00:01

after a person says, yes, I'm interested

1:00:03

on your contact page.

1:00:05

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

1:00:08

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

1:00:10

I've had a lot of patients from

1:00:12

my former practice, try to follow up with me.

1:00:14

Some of some continue to follow me. Some,

1:00:16

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

1:00:19

But I I'm a big fan of calling,

1:00:21

cause again, I, that's where I think

1:00:23

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

1:00:26

really answer questions and sell myself

1:00:29

when necessary. So, I

1:00:31

tried to, I'm also trying to eliminate

1:00:33

the tech. I love tech. I know you

1:00:35

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

1:00:37

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

1:00:39

the human interaction. So,

1:00:42

I try to call the patients, text them as soon

1:00:44

as possible. Like I just had a, I

1:00:46

had a patient the other night, they texted

1:00:48

me like at eight o'clock at night.

1:00:51

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

1:00:53

like, sure. So, I

1:00:55

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

1:00:57

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

1:00:59

that everybody does it. But like, I

1:01:02

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

1:01:04

I, as if I was a patient,

1:01:06

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

1:01:10

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

1:01:12

is really excited to talk to me.

1:01:14

Like, I want my patients to

1:01:16

feel that way.

1:01:18

I love it. And I will quote Dr.

1:01:20

Dr. Amber Beckenhauer, you do you.

1:01:23

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

1:01:25

let me ask you now about the website

1:01:28

and the analytics. When you started,

1:01:30

did you have the video that exists of

1:01:32

you talking about the practice on the website?

1:01:34

Or was that something that you added on later?

1:01:37

That was from the, that was kind of from

1:01:39

the very beginning. And part of that also

1:01:42

was. I had the website

1:01:44

up prior to me actually opening, but

1:01:46

then I just kind of de identified it, so like

1:01:48

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

1:01:51

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

1:01:53

was like a countdown timer of,

1:01:55

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

1:01:58

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

1:02:00

takes and it was like, again, I

1:02:02

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

1:02:04

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

1:02:06

Like, that sort of thing. And, but

1:02:08

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

1:02:11

exercise because I was like, I had to really concisely

1:02:13

tell people what it is that I do without,

1:02:16

losing their attention, that sort of thing. But but

1:02:18

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

1:02:20

things I'm working on and I'm hoping

1:02:22

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

1:02:25

I love it. It's such a transition from

1:02:27

what you shared, early on before your

1:02:29

direct specialty care journey in

1:02:32

working on the business, that's not a thing

1:02:34

that we do when we're employed.

1:02:36

So, now let me ask you here about

1:02:38

the, The places that people most

1:02:41

visit on your website, do you see

1:02:43

that people are visiting a particular

1:02:45

page more so than others? And have

1:02:48

you adjusted your website to, to

1:02:50

speak to that data?

1:02:52

It's the way I have my, my website

1:02:54

set up, it's Basically the landing page

1:02:56

is the main page, so they don't

1:02:58

really have at least analytics

1:03:01

wise. They don't really click past that

1:03:03

too much because everything is on there. And

1:03:06

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

1:03:08

clicking and I try to avoid clicking. I assume

1:03:10

everyone doesn't like to click. So, I

1:03:12

haven't really noticed any people kind of venture

1:03:15

off too far from the click. I've noticed

1:03:17

a lot of people will just go off a straight

1:03:19

Google, like you Google search and then like

1:03:21

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

1:03:23

had a lot of people just go straight off of

1:03:25

that to call. I never really understood what

1:03:27

all those hyperlinks were, but now I do. On

1:03:30

the side. So, getting your, getting

1:03:32

your, your Google straight is, is super

1:03:34

important for sure. I, I. I've

1:03:37

always known it was important, but it's,

1:03:39

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

1:03:41

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

1:03:43

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

1:03:46

your Google business account, grab it for yourself.

1:03:49

That took a while that, that took a long

1:03:51

time because I had all these

1:03:53

great reviews with with my old practice.

1:03:55

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

1:03:58

it back to me. So I

1:04:00

opened up a separate Google, a

1:04:02

separate Google business. And then it turned

1:04:04

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

1:04:07

and then I had to consolidate into one. It

1:04:09

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

1:04:11

you know, it, it took a couple

1:04:13

months to get that thing straightened out. So

1:04:15

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

1:04:18

I looked really messy online. Like it showed my old

1:04:20

practice. It said I was permanently closed

1:04:22

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

1:04:24

was a mess, but yeah.

1:04:26

I totally echo that. And that's something

1:04:28

that even if you are employed, you can

1:04:31

still. Claim your Google profile

1:04:33

as like doctor so and so. But

1:04:36

yeah, I'm going to challenge people like if

1:04:38

you are posting this week, anybody on social

1:04:40

media tag my DPC story

1:04:42

and put hashtag stupid

1:04:44

postcard on your post because

1:04:46

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

1:04:48

nuts. I mean, I was like, wish that

1:04:50

I had done my Google page earlier, because

1:04:53

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

1:04:55

I don't have a physical mailing address, you

1:04:57

have to mail to P. O. boxes,

1:04:59

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

1:05:01

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

1:05:04

So thankfully it worked out

1:05:06

that I could, I could send it to somebody who

1:05:08

did give me the postcard from my address

1:05:10

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

1:05:12

my gosh, so mad. So yes, like,

1:05:15

I totally agree with you though.

1:05:16

Yeah. Yeah. But I did, I do think

1:05:18

that did help a lot, so it, I

1:05:20

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

1:05:23

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

1:05:25

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

1:05:28

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

1:05:30

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

1:05:32

if you have good reviews on there. So

1:05:34

how about, because. When you spoke

1:05:36

about your contracting with the Navy

1:05:39

keeping up your set of skills was important

1:05:41

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

1:05:43

services to other people? How are you focusing

1:05:45

on making sure that your scope of practice

1:05:48

is still where you want it to be going forward?

1:05:51

I think part of it is actually trying

1:05:53

to, number one, I don't

1:05:55

think I want to be a big practice ever

1:05:57

again. So having a single

1:06:00

room is very intentional. I

1:06:02

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

1:06:04

anxious that it's not filled. You

1:06:06

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

1:06:08

number, that's probably the main thing that

1:06:10

I'm doing. I think number two is actually

1:06:13

kind of narrowing my focus and narrowing

1:06:15

down my skills. Like I, I

1:06:17

like doing spine injections, but I don't

1:06:19

think that it's necessarily something I have

1:06:21

to pick up again. So, kind

1:06:24

of narrowing my focus and, I don't want

1:06:26

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

1:06:28

one part of my practice in order

1:06:30

to make this work. That was a real, I

1:06:32

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

1:06:34

for some people because I

1:06:36

think if you're going to have an interventional

1:06:39

pain practice, It's very overhead

1:06:41

heavy. And I have met some people

1:06:44

trying to do the same thing and. And

1:06:46

they had to kind of convert back into some sort

1:06:48

of hybrid. So you have to kind

1:06:50

of be okay with, with either managing

1:06:52

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

1:06:55

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

1:06:58

I'm really trying to just

1:07:00

keep my practice as small as possible.

1:07:02

Like, I, I feel

1:07:04

the urge to get back on the wheel and just

1:07:06

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

1:07:09

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

1:07:11

it. I think I could be stressing

1:07:13

out about not being busy right now. And

1:07:16

I am busy, but I think you almost

1:07:18

have to really take

1:07:20

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

1:07:23

earned back. I've, I've been

1:07:25

in practice or in business now since

1:07:27

for the past four and a half months, and

1:07:29

I've. my kids

1:07:32

go off to school and come

1:07:34

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

1:07:36

them. So I,

1:07:39

and I've probably spent the most time

1:07:41

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

1:07:43

which is great to like having lunch with them. So

1:07:46

I think really starting to actually appreciate

1:07:48

the non, Business benefits

1:07:51

is probably larger than the business

1:07:54

itself. So I've kind of curated my

1:07:56

life to kind of really just be about family.

1:07:58

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

1:08:00

always important. It's, it's

1:08:03

very easy to get busy. I'd looked

1:08:05

at some opportunities where I would be traveling

1:08:07

and expanding my practice a little bit, and I

1:08:09

automatically kind of have to draw myself back.

1:08:11

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

1:08:14

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

1:08:16

doing this. We, of

1:08:18

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

1:08:20

to, to have really gainful

1:08:22

employment and things like that. But I

1:08:25

think you have to find what something else

1:08:27

that's not practice related to

1:08:29

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

1:08:31

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

1:08:33

out.

1:08:34

And I think it really speaks to you

1:08:36

valuing yourself. You're able to see that

1:08:38

about yourself also. I think that when

1:08:40

you're so, nose to the grindstone,

1:08:43

it's really hard to see things

1:08:45

like that and what is really driving your

1:08:47

future. So, That said,

1:08:49

you have said in, you've

1:08:52

said before publicly that your job

1:08:54

will never love you. And you talked about

1:08:56

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

1:08:58

whether it be your son turning 18, so you could

1:09:00

retire from medicine or other timers.

1:09:03

I want to ask specifically about your

1:09:05

direct care practice now. One,

1:09:07

do you have a timer and what is

1:09:09

that timer for if you have one? And

1:09:11

do you and do you find that

1:09:14

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

1:09:16

you because you're a direct care doctor?

1:09:19

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

1:09:21

I the time I still have one

1:09:24

timer. That's for my son when he when

1:09:26

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

1:09:28

more for it actually more probably makes

1:09:30

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

1:09:32

the nest is getting, closer and closer. But

1:09:34

in terms of like, will my job

1:09:36

ever love me back? It's not

1:09:38

the job that loves me back. I think

1:09:41

it's I think that the patients actually

1:09:43

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

1:09:45

But like, I feel I feel the patients

1:09:48

more than I ever used to. I

1:09:51

used to be ashamed of or she I am

1:09:53

ashamed of it now. But like, I

1:09:56

would see people at the grocery

1:09:58

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

1:10:01

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

1:10:03

I would kind of cower because I was like, I

1:10:05

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

1:10:07

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

1:10:10

I, I think being

1:10:12

more connected to people was a big driver.

1:10:15

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

1:10:17

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

1:10:20

people to connect with me and maybe that's a

1:10:22

better way to say it is

1:10:24

that I feel probably more connected to people

1:10:27

in general than I ever have before. And

1:10:29

that was really one of my, that was one

1:10:31

of my strengths. Prior to medical school,

1:10:34

it was like at my ability to connect with people.

1:10:36

And so I, in terms of, is it

1:10:38

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

1:10:40

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

1:10:43

an opening to, to feel something.

1:10:45

So I think I was just like, like

1:10:47

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

1:10:50

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

1:10:53

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

1:10:55

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

1:10:57

the year prior to

1:11:00

me actually leaving I was getting,

1:11:02

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

1:11:05

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

1:11:07

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

1:11:09

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

1:11:12

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

1:11:14

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

1:11:16

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

1:11:18

be right back, and then I would leave.

1:11:21

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

1:11:23

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

1:11:25

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

1:11:27

saw cardiologist, stress test, normal,

1:11:29

normal, normal. The

1:11:32

day I decided to quit was

1:11:36

the last time I ever had that chest pain. And

1:11:39

to me, I was just like, wow,

1:11:42

I and even as I'm a very introspective

1:11:44

person, and that to me was like, very,

1:11:46

very eye opening. It never occurred

1:11:48

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

1:11:51

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

1:11:54

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

1:11:56

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

1:11:59

I woke up, I'm glad that my my

1:12:01

kids honestly, they would

1:12:03

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

1:12:05

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

1:12:07

just very thankful.

1:12:10

Amazing. Well, we are all thankful

1:12:12

for you sharing your journey today. Thank you so

1:12:14

much, Dr. Bargaras

1:12:15

absolutely. Thanks for having me on.

1:12:21

Thank you for joining us for another episode of

1:12:23

My DPC Story, highlighting the physician

1:12:25

experience in the world of direct primary

1:12:28

care. I hope you found today's conversation

1:12:30

insightful and inspiring. If

1:12:32

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1:12:34

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1:12:56

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1:12:58

and keep advocating for DPC. Read

1:13:01

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1:13:04

com. Until next week, this is Maryal Concepcion.