What Nobody Teaches Doctors About Running a Practice

**[00:00:00]** Hello everyone, my name is Amando Piscaro and welcome to the web talk show. Today with us we've got Dr. Rishin Sha from Prime Heart and Vascular and Goline Healthcare. How are you Dr. Rishin? >> I'm good, thank Armando. Thanks for having me. >> The topic of today or maybe multiple topics will surround the medical space. We'll talk a little bit about the cardiology, vascular but also the business side of things. And so as our listeners know, the web talk show is about hearing the behind the scenes of what happens in different types of industries, different types of businesses. So I think this is going to be very interesting because most of us just see the physician as the physician and it's something where we visit but we don't see what happens behind the scenes and everything that takes place. So I think we're going to have a very interesting conversation. So let's start off with a little history uh behind you. Rasheen, can you give us a little brief background on who you are and what you're doing now? >> Uh sure. Uh professionally I'm an interventional cardiologist. I've been in practice um for more than a decade at this point. Um and I've been running my own practice um since 2018. Um, and so I've really learned the ins and outs of running a medical practice. And we do actually have three other medical practices we run as well. Um, and that has been quite the learning experience um, from the business perspective. Um, of course my first love is taking care of patients um, as well. So the cardiology part still does take up majority of my time. But talking about these things, thinking about the business aspects and how to operationalize a **[00:02:00]** lot of things to help help us out, help patients out is of immense interest to me. >> That's great. I've heard other physicians and people in the space do that transition where they're in treatment and care and then they go into making the business better and then they get into actual business and then helping other businesses and helping other physicians with their things. So I think it's a very interesting jump there. Why did you start in your case to do that job instead of just staying in and maintaining your practice? It's become really interesting because in 2025 it's really hard for a physician to stay independent and when we say independent they are not employed by a hospital system. The incentives with medical insurance makes it so for the same work you know you see a patient maybe do a test or procedure the hospital is getting paid significantly more. There's something called facility fees. So if I see you, you know, one of the downsides of insurance is I never know exactly how much I get paid. So if I see you as a patient, you know, just assume I get 150 bucks. Um the same doctor seeing a patient in the hospital system can double or triple that, you know, that amount of money. Um they the hospital gets something called facility fees. And so as inflation has gone up, right, our costs are gone up, wages are going up, our our reimbursement, the amount that insurance gives to us because remember, we don't decide what you pay. It's the insurance company that decides what you pay. And we just have to follow our contracts. So they decide to pay us less. Our costs go up. Um, and I feel like private doctors **[00:04:00]** are probably are the best places to get care. So, I really want to help other physicians stay private and so they can continue to give out good value, good care to our patients. I'm glad you touched on that. I want to go a little bit deeper because I've had this conversation recently. If someone goes to you directly, they pay a price, they know how it is, how much it is, you know how much it is. friend recently had to visit a place to they were going to check something. It wasn't anything major. It was just like and they asked, "Okay, so how much is is it going to be?" Because they wanted to pay right there. And they told them, "Oh, oh, no. We'll we'll send you the bill." And they're like, "No, no, no, no, but just just I just want to pay right now cuz we No, we'll we'll send you. But how much is it going to be?" No, we don't know. We have We don't know. Eventually, you'll get And he was so confused. He wasn't from here, so he was so confused. He was like, "How is this how is this going to how can they eventually decide how much they're going to charge me? The thing already happened and it was just very confusing." And I've had that experience before as well in hospitals. And so it's very interesting to me that like you said right now, you have a private practice. I can go and you'll know how much to charge and I'll know how much to pay and you can have a payment plan and all that. But the reason we know how to how much to charge, I have one full-time person that that's their whole **[00:06:00]** job is to figure out what that cost is. It's something called time of service payments. >> So, how much should we charge you? And it's all completely dependent on insurance. There's, you know, terminology like deductibles and co-ay and co- insurance, which I barely understand, you know, being in this as a practicing physician. Um, but I have one full-time person because it's very important to have that insight, right? When you come in, how much is this going to cost? >> Instead of getting surprised, oh, I thought this was going to be 100 bucks, but actually you got a bill for $400, right? So, trying to be as best as we can to figure it out. Um, what one thing that people don't realize as well is insuranceances give wrong information a lot, you know, and they always have this caveat that until the claim is filed and build, they're not on the hook for anything, >> you know. So, you try you talk to you could talk to two different three different representatives and they give you all different information. They have online portals that may give you different information, you know. So, it's the amount of effort it takes to get paid versus going to the local sandwich place, you pay five bucks, you get your sandwich in return >> is immense. And so, um, as you can imagine, if you have one full-time person just doing that one job, >> how many people and how much effort it takes to kind of run a practice? >> That makes sense. Now, what if you did it cash only? Are there any practices that work that way? >> Yeah, so there are the cash only practices. Um there's a big movement nowadays called direct primary care. **[00:08:00]** >> Mhm. >> As in the name, it's mostly in the primary care space where you pay like a monthly subscription cost. >> Okay. >> And and it's it's very um um affordable. For example, $150 a month you get as much care as you want by that doctor. You know, labs and imaging would be extra, but all those prices they've already negotiated with someone and they're upfront on their website or you know how much you're going to pay. And so whether you go to them every single day of the month or you go to them once a year, you're still paying that subscription if you write like, you know, software and all all these other kinds of >> like a gym. >> Yeah, a gym, right? You're paying it whether you go use it or not. And so um that makes a lot of sense and more and more people are going down that road. I just saw one the other day. I was driving here in town and I saw one and it's a direct primary care and I I took a picture of it because I was wondering is that what it means? Is it like non- insurance type thing? And indeed, I looked them up online and it was a membership type thing like you were explaining. That's very interesting. How how would someone, let's say someone does that, do they I think what I'm trying to get at is there's there's this fear. I think we all have insurance because of fear, right? You don't want to not have insurance because something maybe in the future might happen. And since hospital bills are tremendous and you might get a bill for $100 to $200,000, you're like, I don't I don't want that **[00:10:00]** to happen. So you buy fear or because of fear pay for the insurance. And so okay, but [laughter] maybe you never use it, right? And then maybe the services that you try to get from your doctor that they give you, you're not getting the best care. or maybe the the one that's fits in your insurance doesn't have the best treatment for people or you don't feel at home or whatever and then maybe a direct physician will give you a much better experience more more tailored. Why why does it why do we all fit into this box of having to do the insurance having to do it that way where like you said this new movement is coming along. Is there a way to do it without the insurance or do you always for sure have to have that just in case? Like are we all stuck in that or do you think at some point in the future there might be a a day where it might all be just sort of private if you want to? >> No, I mean I definitely recommend having health insurance still. I mean it's meant to be at least for catastrophic, right? >> Mhm. >> Like in my specialty cardiology, you never know if you're going to have a heart attack, right? You might be feeling fine and then the next day you're shoveling snow and then boom, heart attack. So you got to have the coverage or you get cancer, right? You know, unfortunately all that stuff costs a ton of money. So you got to have that catastrophic coverage. There are non insurance products, you know, like Medshare plans. Um, frankly, because health insurance has become so um expensive, I just switched our family um to **[00:12:00]** like a crowd sharing platform um for our health needs. Now, they're very careful to not call it health insurance because it's not. >> Um but they will fund um you know, major medical expenses. Um we'll see how it actually works out. Um but so a lot of people do this direct primary care plus one of these maybe mediare or um you know there's these Christian sharing plans or crowd health plan crowd health is one of the companies that's the one I personally use um starting this year um but you got to have some sort of coverage in case something >> of course happens just like car insurance right you don't use it for your oil changes that's analogy people use exactly >> you know you use it if you get in a car accident so um maybe for primary care you just go cash pay, but if you need to see a specialist or get, you know, imaging or surgeries, then you use your health insurance. >> Interesting. Okay. I didn't know those other crowdbased programs existed. That's something interesting myself and maybe other people want to look into because Yeah, like that's a perfect analogy. You you don't get car insurance to get oil changes and things like that. I mean, you sort of do when you buy a new car and they're like, "Oh, we'll include maintenance for the first four years or whatever." Yeah, that's basically what you're doing. But it it makes perfect sense. Yes, I agree. You should have something for catastrophic events. But then everything else, I mean, it's not by if I just want to pay for the doctor visit, I'll I just want to go and I want to go with that doctor. Like I want to **[00:14:00]** go with you. I don't want to go with whoever they're placing for me to go to. Right? Does that make sense? I mean it is very helpful because like for example my practice we typically do things called stress tests and echo cardiograms to assess how the heart is doing if someone for example is coming with chest pain but almost never can I do it the same day cuz we have to get the authorization from your insurance which by the way is a whole another person that does that. we schedule a few days out so we have time to do that versus if it is a self-paid patient and you know I had one yesterday they came in for a visit they were concerned about their chest pain um and I was able to do everything the same day because I didn't have to worry about going to insurance getting the authorization um and things like that so pros and cons to each each system obviously um >> that makes sense is it are most practices hybrid in that sense like you can do cash pay or insurance or or are some just insurance based completely? >> No, I mean I think we'll all take cash pay patients. You know, we want to take care of the person. Um in one sense it is easier like you said you can upfront tell the pricing and the patient wants to come in with whatever pricing and that is a true you know capitalistic system where the doctor can set their price you know with insurance there's no you know setting a price it's based on our contracts and insurance contracts can differ like I could get a certain contract and this guy down the street could get **[00:16:00]** a totally different contract um so nowaday what what what you have is bargaining power is when you have tons tons of doctors under one tax ID. So that's one reason private equity has come in and buying up all these medical practices that they can put them all together under one tax ID have negotiating power with insurance companies and say hey if you don't give us this the 60 cardiologists in the city are not going to be in network and obviously you don't want that because their patients are going to be very upset. Um and people have to do those sorts of things you know um many times in 2025 just to survive. Wow, that is a very good point and it makes perfect sense. The insurance will pay more attention to someone who has more people under them because that will mean more >> It's like you've got your internal >> no one cares, right? So, >> um there are these things called independent physician associations, but you're not under one tax ID. So, everyone's very separate. So, >> um you don't really get any benefit from that standpoint. So for my practice to thrive, we've, you know, we really have to find different ways to, you know, make keep our overhead low and be able to take good care of our patients. >> Oh, that makes perfect sense. Now speaking of cardiology, is that something that people go to you at a specific age and onwards or do is it is it something that someone can I think many of us think of cardiology, oh only when something happens or only when I'm over 50 or whatever. Is is it something that you can sort of preemptively go and check everything's fine? Should you **[00:18:00]** or is it more of a just if something happens kind of thing? >> I mean prevention is great, right? We want to avoid the event. Of course, if you have that heart attack, of course, if you have symptoms as such as chest pain, shortness of breath, you know, those are definitely times to come see us. But say you have high blood pressure, high cholesterol, or you don't have any of the above, but you have family history, you know, those are all definitely uh reasons I would go in sooner. And just to make sure we kind of control your risk factors. So there's not just one thing that causes, you know, heart attack, which is what most people would be most afraid of. It'd be combination of lifestyle, weight, exercise, cholesterol, high blood pressure, um are you a smoker, how much do you drink, how much stress, how's your sleep? So trying to address all those factors and potentially um doing some advanced blood tests, advanced cholesterol panels, um look doing some imaging of the of the heart arteries to see if you are at higher risk. You know, our goal is to aggressively treat the people that are higher risk. >> I tell people that really at at the end of at the you know the the main purpose of me is uh my or my main job function is more as a mathemat mathematician prob you know it's all about probabilities. >> Okay. If you have a very low risk of heart disease, we're gonna say keep doing what you're doing. You know, obviously there's always things you can improve. Versus if you find something makes you at higher risk, we're gonna be like, we want to aggressively treat you, aggressively get your cholesterol **[00:20:00]** down. You know, I'll counsel them more on lifestyle changes, what they need to do exactly so we can hopefully prevent the the outcome of a heart attack 10, 20 years down the line. you mentioned something or I saw something about this in your website and and beyond that you're you like doing sort of minimally invasive treatments if possible. Why do some doctors have a different approach? Let me explain a little bit. I' I've had experiences with people I know close to in the pancreas or something that seemed irritated or something and the first thing was, oh, you have to get rid of X organ, right? Yeah, you don't use it. Let's just get rid of it, right? And you sort of get scared and you're like, why does that make sense? I mean, if it's there, it's probably important, right? And then eventually they did nothing and just fluids and and hydrated and everything and then everything went away and everything was perfect. So it was sort of a one time type deal, right? So, but some doctors will say, "No, no, no, wait. Let's see. Wait it out. Let's see how it's how you're behaving. Eat well, etc., etc." And others take the more, "Yeah, let's just get rid of it so it doesn't happen again approach." What do you see there with your approach versus others? I think one part of it is how you interpret the data, right? We are all very science and evidence-based. Um and so how we interpret it, we all have our own biases as well. Um I like to kind of use every tool we have in the tool belt, you know. So whether it be lifestyle changes, whether it be medications, I mean I do interventions, **[00:22:00]** right? So that is also part of my tool belt. So I think that's one benefit is I can do everything. Um but because I'm so focused on lifestyle and minimally invasive, that's probably my bias. Um and and the data in cardiology is actually very clear and this is always very hard to explain. If you have a blockage in one of your arteries and it's stable, going in and putting in a stent uh is not going to save your life. It's not going to prevent a heart attack. Um and just sometimes communicating that to patients is is a long conversation. It's like, but I have this 80% blockage. You're saying you don't need to fix it. I'm saying I don't need to put a stent in there. I still need to treat it. We still, you know, blockages are made out of cholesterol plaque and, you know, we need to get that lower. We need to adjust your lifestyle. We need to get your diabetes under control. We're still treating it. You know, stances are like a spot treatment. You know, if you're having a ton of discomfort and we've tried with medicine and that's not working, yeah, opening it up um to get blood flow so you don't feel bad. But it's a systemic process called aththerosclerosis. So, we need to work on it systemically. Um so in the cardiology space you know there can be different opinions about that. Um doctors like when I go to say bias right we may have seen that what this one patient from a decade ago where maybe they did have that blockage and you know something bad eventually happened to them. Science works on a you know you know big public level right like 20,000 patients. M **[00:24:00]** >> you got to always decide with that patient in front of you what makes sense for them, right? They're not going to be that exact patient that they had in that trial. There might be confounding factors that you got to take into account. Um and so it's hard to say on a patient to patient like that example you gave with the pancreas, right? I wouldn't be able to say anything about that. Um but it's always taking the history, listening to the patient, taking that information, and then deciding what's best for them. >> I think that makes perfect sense. science is very useful. Like you said, sometimes we think we're doing science, but really we're just looking at a very small sample and it's not really a valid sample. So So it happens our minds sometimes do >> and honestly evaluating science is very difficult. You know when you know my sister says, "Oh, I did research on this." No, you didn't do research on it. You did a Google search or nowadays, you know, chat GPT search. people that evaluate science all day for a living find it hard, you know? So, it's really hard to evaluate science. Um, but the goal is you take, you know, it's not just any one article, right? Like people will say, well, this article says this, you know, they're always confused because the news will talk about one article. It's taking the breadth of evidence, the breadth of data, and trying to see, you know, what they've been saying for the last 20 years on this topic. >> Yeah. What on that topic? What's your take on AI in the not like oh let me ask judge PT but more of a if you're following a scientific approach **[00:26:00]** and you have access to tools that will examine like IBM Watson the supercomputer type thing where you you use AI and computing to abstract data from large data sets and understand like oh okay yes this case like you were saying is similar to these 2500 other cases is because of these factors and then that can help you maybe make better decisions. >> So for physicians there is actually an AI tool called open evidence. >> Okay. >> And so it looks at um articles. Um however just looking at some of the data on it. It's not super accurate yet. You know I think the obviously with all this stuff the prompting matters a lot. Um but it does give wrong information sometimes still. So I mean the the benefit of it is it does point to the source articles. So you can always go to the source articles. Um but yeah 100% there's you know the amount of knowledge that to keep in here just keeps expanding expanding. So there's no way you know so you know we do have to look things up sometimes right like I don't remember everything about every body system and things like that. So yeah, we do use um tools and AI has made a lot better compared to two decades ago or where you or you know three decades ago at this time where you got to go to the library and open up a book, right? Try to find that passage or that that that journal article. >> Um but I think yeah AI is definitely the future. >> Is there a benefit of wearables for for what you do cardiology specifically? I know sometimes there's these apps and they measure your pulse and they tell you if **[00:28:00]** there's some sort of rhythm difference or whatever and are they useful? Are they helpful? Are they I mean accurate enough that they can give you a good idea if you have to go somewhere to be checked. I think one it's great for bio feedback right to one of the best ways I've used it for not just myself but patients is just something as simple as steps right we know the more steps you do the more active you are lower your cardiovascular risk is and so the past probably year patient comes in they have you know they're like I'm like how much do you walk you know I do my five six thousand steps a day probably you know but I I don't really track it's like have your iPhone with you all right it tracks everything for for you, right? You got your Apple Watch, it tracks everything for you and you can pull it up and then, you know, I give them a target. You know, try to go up by a thousand steps a week or a month or, you know, based on wherever they're doing. Um, so that's been really helpful. The EKG thing, there's a device called Cardia, um, where they can actually put two fingers on it, it tracks EKG, um, especially for people had certain kind of arhythmias or regular heartbeats. I do think that's useful. The Apple Watch does um um say if you have this particular arhythmia called atrial fibrillation. Um there's definitely false positives, you know, like it'll say something's that and patients will come to me and I look at it, but it does help me too because I have those strips versus having to maybe order another test. I can look at those strips **[00:30:00]** and be like, "Oh, no, that's not a or yeah, that is Aphib. We need to kind of do all this other stuff." Um so [snorts] I think it does help compress the amount of time it takes to to get care. Um so I think do think it's it's useful in those ways how much sleep you're getting you know um it's actually helped me get sleep right because I I was saw that I'm getting like 5 hours sleep and so I just stay in bed now longer and I do get a little bit more sleep. So um it has been useful in those sorts of ways. >> Yeah that that is true. you at least have it top of mind where sometimes you're like, I don't want it to keep bothering me to stand up or something. But at the end of the day, it's like, well, if it telling me to stand up, it means I've been sitting down for an hour and not doing anything. >> Yeah. Prompting those sorts of things. Yeah. Like the activity thing on the Apple Watch, right? That that's >> Do you get any sort of data? I know I I've never used it in that way, but you you get information as a person on the watch, right? But then as a consumer, I would say it has a way to sort of link or I think it has a way to link or send that data over to a physician. Is that something that that you've seen before? Does it actually happen? Like can you get more data out of it for your patients? >> Um I'm not honestly sure about that. Yeah, I didn't know that was >> No, I've never seen that side of things. **[00:32:00]** I've always wondered like I know there's some sort of connection possibility or export. I don't know but but I've I haven't interfaced with it. But I I expect it would be very nice if you could have it connect to I don't know some sort of system such that you would get all the data instead of just going through their phone and and >> yeah there's not and for the Apple Watch but there's something called remote patient monitoring that we do that if patients have like a blood pressure cough or some kind of connected device that yes and you'll get blood pressure readings automatically to your portal and so if if it's high you can reach out to patients you'll get notified um and that's something that a lot of practices do these days. >> Oh, that's very neat. So, so there are devices that you would give a patient if you want to keep track of where they are. >> Yeah. For cardiologist, usually the blood pressure cuffs, the biggest one, but we also give out scales and glucose monitors. Lung doctors will give out some oxygen meters I think sometimes. So any kind of vital sign that you want to track and then it can be imported on on an online portal and the staff member gets notified if you have a high or low or if you need to do something with the patient to notify him or try to make or make some medication adjustments. For me more data the better. So, you know, coming into the office with just the office blood pressure, you know, sometimes it's hard to tell what to do, how, you know, but if I get a whole bunch of data from what it is at home, **[00:34:00]** assuming you're measuring things properly, that just helps make decisions much easier and better for the patient. Do you think when someone is not obviously not to tell people to spend money, but let's say someone is wondering about their blood pressure, etc., and they have the option at the pharmacy or wherever Amazon to buy just the regular pressure cuff or the one that actually saves the data and connects it to the cloud or whatever. Is it worth it to to get someone something that that keeps the data so that then the doctor can see it or is that >> I mean any I mean if they can keep a pen and paper copy the electronic copy this remote patient monitoring you know actually health insurance covers so they would get a monitor through their insurance company um but yeah anyway works um just more data the better >> as long as you have it right. Okay. Now in the medical space there's this topic that has been coming up a lot which is um voice AI or I've covered it many times in the space in the podcast getting your front desk staff more time and what I mean by that if if people who are listening haven't heard those episodes is there's a huge percentage of calls and you know this because of your practice that get missed And so nowadays, yeah, we we've talked about I won't get into it too much here, but we've talked about like having voice AI receptionist, that sort of thing that can help you offload some of those calls, but then there's also the human part because I know a lot of people are like especially in cardiology or things like you're not just booking a I just **[00:36:00]** want my regular care visit for the year. In those cases, yeah, Boycei is perfect. It'll work. And actually, it's just it's really good. You you just feel like you're talking with someone. They'll get the booking very fast. Nobody loses time and you're in. You're not on hold for for 30 minutes, right? But and and you brought this up earlier, there are types of practices like cardiology, I expect, where most or many of the calls are people who might be have chest pain or or are going through something and they might want that sort of warm connection to someone who's who's going to listen to them and actually do something in that moment. So I know you work a little bit with that in Golene as well. So can you tell me a little bit about how that came about and what difference it makes to just have your one or two people front office staff versus having something like Goline behind you? >> Yeah. So Golene is a staffing company. Um we use offshore staffing um all over the world um but predominantly from the Philippines just because there are a lot of nurses and medical people um and they speak more American English just cuz America was there for a long period of time and the key benefits are outside of that is they see this as careers. Um they care they get paid very well compared to what they would get paid in in in their own countries. Um, and speaking of like a receptionist, that's usually where most of our clients use use them. A metric I I've read multiple times is in service based business is 30% of phone calls get missed, right? And so, think about being the patient on **[00:38:00]** the other line, on the other side of the line, right? You're worried about something, you have some symptoms, you need a medication refill, um, and you're trying to just get through. someone please pick up and listen to my concern. Right? And they're just sent a voicemail. And you're in this nebulous time period of when you'll get called back. Is it 24 hours? Is it 48 hours? And on the other side, the medical assistant is swamped, right? They're trying to check in a patient. They're trying to take a phone call, trying to send in a prescription refill. So, how do we balance all that? Plus, the the doctor has to be able to pay his bills, right? you can't hire 20 people in the US because that's going to bankrupt you. So, how do you try to balance all these aspects? Um, so for me, a big part of it was going offshore, you know. So, ever since we did that, we we keep metrics. We don't ever miss phone calls. It is not hard for me to hire if we start getting more patients, more phone calls because it doesn't, you know, break the bank. And you're you're right. I, you know, I think voice AI is great. Um, but especially in, you know, my practice, if you're calling, you have chest pain or, you [snorts] know, you had a friend that just had a heart attack, now you're concerned about yourself, >> you want to speak to someone, right? You want to speak to someone. You want that empathetic, compassionate voice >> that can help you out. And frankly, navigating the medical system is hard with health insurance and you know all HMOs, PPOs, patients don't know all that stuff. Um, and so I **[00:40:00]** think that the initial person, the initial call should go to a person. >> Um, do I think AI has a usage? Yeah, as you mentioned, I think having a human in the loop type AI where um you know the patient one gets to choose, hey, you if you want to use our AI tool for scheduling, go ahead. Or um if the patient calls in for a prescription refill, because usually the front desk person isn't the one doing the prescription refill, it goes to AI and routes it to the right person and so it actually gets done quickly. you know, >> um even like things that are not purely medical but like billing, >> you know, patient can talk to AI, you know, and give all the information. Um but the billing person always has to do research. Can AI condense that and put it all into the exact stuff that the billing person needs so they can look at it and get back to the patient even quicker? Um I think those all have great uses. Um we do a lot we do outreach right now. um trying to get patients to come in, get, you know, come in for their yearly appointment or whatnot. I think that's also a great tool for AI, right? It's like, hey, it's been a year since you came in. Your prescription is due. Um please come in so we can assess how you're doing, make sure everything's okay, and then we can send your prescription refills. >> Um so I think it's a combination of delegation, you know, with with these offshore staff, >> and then automation, you know, using the technology and AI. And so yeah, we have Goline Health where we've worked with, you know, about **[00:42:00]** a 100 practices and place patients. And you know, I'm also developing a piece of software. It's called Newton Health. Um to help with patient intake, patient engagement. Um and also make doctors more efficient. Um we're trying to do both sides of things. Um and like I mentioned before, I love doing things that are win-wins, right? So it's good for patient care, it's good for the business, it's good for our employees. um offshore as well. >> That's great. I I really like when people do that where they have a business, they made it successful, and then they look at ways to help other practitioners in their space make it successful as well, whether building training programs, software that they can use, standards, tools, etc. It it's really nice because if you when you were started when you were getting started had everything that you know now would get to that point much faster. So, >> right. Yeah. This is just solving problems, right? That's what a business is. You solve your own problem. You see that there's some value. Um, and I'm very passionate about helping independent private doctors um survive and not just survive, thrive, you know. So whatever tools I found that have helped me in my practice um and I talk about this a lot you know there's doctor Facebook groups private practice you know doctor uh WhatsApp groups you know just trying to disseminate information >> um you know because I think we're all we all are kind of hesitant to talk about business you know cuz like doctors are not supposed to think about the money right >> but but frankly if we can't keep the lights on and right we're not thriving in business So I that good doctors are **[00:44:00]** not going to be able to see patients. So it's important, you know, it's important to market yourself, you know, it's important to get out there, show them what you can do. Um, but yeah, I mean, it is getting harder and harder, you know, to to stay in business with increasing, you know, inflation and our insurance reimbursements and competitions with hospitals. So we got to do what we can kind of kind of have to think outside the box sometimes. >> Yeah. Well, you bring up an excellent point. Sometimes we think of doctors as Yeah. Oh, well, they they should do it because they love helping. And at the end of the day, anything you do, there has to be a way to maintain it, keep the lights on, like you were saying. And if you have a doctor, this applies to anything, not just medicine, but if you have a doctor who's not stressed about money, not stressed about staff, not stressed about lack of sleep, then they're going to do a much better job and they're going to have time for research. They're going to have time to give you a better care. They're going to have time to and money or resources to get additional staff so that you don't have to be waiting an hour in the waiting room after your appointment time. And so it it all scales, right? I I've had the experience where as a patient, you go to an office and your time is supposed to be 10 a.m., but they don't see you until 10:45 and you're just there. It makes no sense. But I've had the other experience with the group I'm now, they have a group like you were saying. And so their group maybe has **[00:46:00]** a doctor and two or three nurse practitioners or two doctors or whatever. And they have their front end staff and they sort of share it then. But you go in and you're barely getting your cup of coffee and they're already calling you in and you're just in and out super fast. Why? Because the business side of it is thriving such that they can have everything else around it and you as a patient get better care. Yeah. I mean to this day the thing that brings me the most joy is when I make a real difference in a patient's life, right? That is 100% the reason I got into it. I loved helping people. I love the science of it. The best part of medicine was learning it. You know, being in medical school, being a residency, it's a very long road, but I love learning it and you know, the the whole process of becoming a doctor. Um, but then, right, you get into real world and you've never been taught anything about the other side, which is how to actually run this whole thing and how complicated it is and convoluted it is. You know, again, going back to like the Subway example, you give five bucks, you get, you know, your sandwich. that is not how this works. Um, and then all the systems and processes about like you said trying to get seen on time like is my practice the best at this? No, not by any means. You know, it's a constant constant thing we also struggle with um to try to balance, right? I can't have 20 staff members just sitting around not doing anything. Um, so it's a fine balance of everything. Um, so yeah, it's something we got **[00:48:00]** I'll think about. But if if the business part of things are kind of, you [snorts] know, set, then yeah, you can definitely just focus a lot more on on the patient. I have a question that I think many listeners will will come up with as well when you talk about the virtual assistants that are not in the states, right? We've all had the experience when where you call somewhere and you get this extremely different accent. they don't understand what you're saying. You don't understand what they're saying. You're like, why am I talking with someone in the other side of the world? Nobody likes that experience. But there there's a proper way to do it, right? And that's why you choose from the Philippines and other places. So, can you talk a little bit to that and what makes your approach different from what maybe perhaps many of us have experienced and feel like, hey, why am I not talking to someone just here? Yeah. Yeah, I mean the communication by far is the number 1 2 3 4 fifth thing, right? Like when things messed up, it doesn't matter if you're offer or you know here if the communication is not on point. If you don't close the loop, hey, I'll get back to you in 24 hours, you don't actually get back to them, right? Like those are the the things that get um me upset, get patients upset. When I'm a patient, I don't like it. Hey, yeah, call you back. I'll give you this information. You know, I'm not getting called back. So we do have like a a really good recruitment process, try to find people with the best skills and it's not always in the medical space. You know, my **[00:50:00]** operations director, which is one of my operations director, which is offshore, she came from the marketing and sales space. Her communication is completely on point and she learned the medical side of things. Um, so I'm not just, you know, cookie cutter into they have to be a nurse or this and that. Really depends on the role, depends on what you're looking for. If you're looking for a phone receptionist, yeah, 100% communication, empathy, compassion, those soft skills are what really matter. Um, and we don't just recruit from one place, right? I'm trying to find a players no matter where they are in the world. You know, if they're in Argentina, we have Argentinians, we have Bizians, we have Peru, we have South Africa, we have Indian Pakistan, we have Philippines. So, what are you best at? What you know? So I think it actually is better than just looking in one place right just America like the best people no matter the world there's good people everywhere you know and if and you know obviously you save money with that and these are careers so one of the things people don't I guess probably know about medical offices a medical assistant who is basically right the person you see that puts you in the room gets your vitals >> a lot of them leave frequently you know >> so there is a lot of turnover in private practice u maybe not as much as a restaurant, you know, >> but it's it is hard to keep people sometimes. Um, and whether or not they're just looking for the next step or what they're trying to do, but these are careers for when we're going offshore. They are not going anywhere. Um, as long as obviously treat **[00:52:00]** them right and you know they get their payraises and things like that. That the receptionist telephone communication side of things or are they also in other administrative tasks kind of things? It's really anything where you don't have to be in the office. And if you think about it, most things in a business, especially medical practice, you don't need to be in the office. So not direct patient care. So yes, the the thing first thing people think about is a receptionist. But some of the things we mentioned previously, the the determining of how much a patient owes, prior authorizations, which is we have to get approval from the insurance company that a certain test is done. I do procedures in the hospital, so somebody needs to schedule those. Someone needs to get the authorization for those procedures. Medication refill. We have nurses that are licensed in in the US that can send in those medication refills. um operations, you know, my operations director when I was is offshore. Um and so really anything you can think of, it can be done. Um we have someone, we have a bill, a billing person, right, that sends in insurance claims. >> Um calling patients to try to to see how they're doing after a procedure, after a certain test, how they're feeling. >> You know, it is all done offshore in my practice. Um and many practices obviously that we serve as well. Wow, that's very interesting. Is it a like does one office get one is it a onetoone relationship or are many of these can they be shared? Is it based on volume? How does that work? >> No, it's one to one. Yeah, you know we and we tried doing the sharing thing honestly before **[00:54:00]** and it just didn't work out. There's no, you know, the medical practices are different enough of how that owner or physician or whoever office manager wants it to work um that we place, you know, 30 or 40 hours per week >> only. Um it is a managed service. So we are very involved. >> One of the other things um is that doctors are not I'll say good managers, right? We have never learned how to do that. we can be impatient. Um and so sometimes a physician needs coaching as well, right? Um we coach the the virtual assistant, we coach the physician. We try to be very involved with developing of SOPs, right? One of the services we want to do is here let's write down to the standard operating procedure even if the doctor that practice has never done it. And then you share it and we make sure we're all on the same page, right? There's constant communication, make sure everything is right. Um, so we really want to make these successful partnerships because it is, you know, obviously it's a win-win, but again, if if they can figure this out, if they figure it out with one person, then they'll just keep going and it's just going to make their practice thrive. That's amazing. I I like the idea. I I think when costs are high in a certain location, when you can get the same type or better service, and this is the same thing that I talk about with voice AI, if it can do the job better at a lower cost, great. If it's going to do it worse, >> yeah, >> even if it's a little worse, no. No, because just give the job to the person here, right? **[00:56:00]** But if the virtual assistant is doing a better job and they're just because of circumstance that's where they are and they're getting paid well over there, but it serves a business here, then there's there's no problem in that. I don't see any problem. I think I think it's it's good business, good economy, like [snorts] you said, win-winwin as long as you're giving that quality of service. >> Yeah, you got to give. Right. It has to. Right. And it's an it's a staffing company, so not a 100% success, right? right? There are people and as much as you try to recruit the best you can, you're going to have occasional people that don't work out, but you know, we have, you know, about a 92 to 95% satisfaction rate. So, the vast majority of times it works out and people need to change the person, we're very happy to help them with that. Um, but yeah, I mean, as long as they're giving good care, you know, they're doing what we ask. Um, and that goes for any employee, right? Um and then you know because this is medical you know patient privacy and all that stuff is also very important. So you know we're do lots of training on what's called HIPPA. It's just how the compliance factor you know [snorts] lots of training on patients uh health information and keeping it safe um and and and communication skills like we talked about before. So yeah, and then you know a lot of the specific in the Philippines, a lot of them have to travel 2 hours to work. Typically this they get to work from home. You know, we make sure that their setup is great. Um, and they get paid 2x what they **[00:58:00]** would normally get paid. Um, so like you said, yeah, better job. They're getting paid more. We're saving some money. The patients are getting their phone calls answered. So, um, I think good stuff all around. >> Amazing. Well, congratulations on what you're doing. I think that it's just it's good. I think it's a very important mark of the successful entrepreneur to then go and help others grow the same way they have. So I congratulate you on doing that part of it. And of course we also being a good doctor and caring about people that is sometimes we forget we think we re we deserve the care from the doctors because we we deserve to have the insurance or whatever and they should cover it for us. But but I mean we're all people and the fact that doctors are there to take care of us and something we all should value a lot more. >> Thank you. No, we appreciate that. But yeah, I mean we we all love taking care of patients. That's why we got into the first place. And if there's ways that, you know, we can figure out how to survive and thrive to be able to do that, you know, whether it be through, you know, my VA company or any other VA company or using software, uh, AI, you know, I think we got to just think about every possible way to to to get things going. >> Amazing. Well, thank you so much for joining us today, Dr. Sha. Where can people find you if they're interested in learning a little bit more about you and your companies? Um the virtual assistant company is called Golen Health. Uh you can go to glean golen.health h. Uh my practice is **[01:00:00]** called prime heart and vascular. We're based in the Dallas area. That is primehv primehv.com. Um and maybe I'll plug the software we're working on too. >> Yeah, of course. >> It's called Newton Health like Isaac Newton. Nehealth. Hal.ai. AI. Um, so yeah, got a few things going on. Um, but Armand, I appreciate your time. This was a great conversation. >> Thank you for joining. >> Thanks.