Welcome to the Oggs Your Gynecology webinar series. I'm Dr. Eva Welch, member of the Oggs Educational Committee and moderator for today's webinar. Today's webinar is entitled, Become the CEO of Your Life, How to Build an Independent Private Practice. Our speaker today is Dr. Allison Wyman. Dr. Wyman is a board certified and fellowship trained URPS physician who specializes in caring for women with bladder leakage and pelvic floor disorders. She completed a residency in obstetrics and gynecology in Cleveland, Ohio at University Hospitals Case Medical Center, Case Western Reserve University School of Medicine. She then completed a three-year surgical fellowship in Urogynecology and Reconstructive Pelvic Surgery at the University of South Florida in Tampa, Florida. She is a faculty member at University of South Florida for five years, and then recently started an independent private practice, Florida Urogynecology Specialist, to better serve patients and the surrounding physicians with a more patient focused care and improved patient access. She has extensive experience in minimally invasive surgical and non-surgical treatment options to offer women suffering with urinary incontinence, overactive bladder, and pelvic organ prolapse. Dr. Wyman has published over 25 peer reviewed manuscripts, surgical videos, and awarded four grants to present her research work and pelvic floor disorders annually. Nationally, she has been recognized as a leader in the field and invited to provide national lectures and serve as faculty member for national medical education courses. Before we begin, I'd like to review some housekeeping items. The presentation will last around 60 minutes. The first 45 minutes will consist of lecture and the last 15 minutes of webinar will be dedicated to Q&A. AUGS designates this live activity for a maximum of one American Medical Association Physician Recognition Award, category one credit. To claim your CME credit, you must log into the AUGS e-learning portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live streamed. The recording of the webinar will be made available in the AUGS learning portal. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues. AUGS staff will be monitoring the chat and can assist. Dr. Wyman, you may begin. All right, well, thank you so much. Thank you for that introduction and thank you to AUGS for providing this platform. And so today, essentially, it's a little bit of a non-traditional discussion and presentation. And this was actually supposed to be part of the early career day that was gonna be at AUGS, you know, PDF week. And unfortunately, and this was gonna, and essentially AUGS asked me, you know, to do an extension of that talk because I was unable to provide it at the time for personal reasons, secondary to hurricane issues. And so again, I really appreciate them giving me the platform to kind of provide some of this education that many of you might find interesting or helpful. And I just really wanna be here to share my journey and share things that I've learned and maybe help some people who are looking for different transitions in their careers. So I'll go ahead and get started. So essentially financial disclosures I have listed here and really nothing that's gonna pertain today to the discussion. So part of that early career day that we kind of designed for AUGS PDF week was really to have an opportunity to talk about different things that were a subset from the routine research and educational discussions and talks and platforms that are at AUGS. And one of the things that we wanted to talk about was work transitions and why people at different times in their career wanna do a transition, right? And so any type of work transition is gonna include new employment, like at a new location, new careers, new roles. Oftentimes people look for these work transitions to increase their overall happiness. They're looking for a better work-life balance, maybe improved job satisfaction, new opportunities for individual growth. There can be a variety of reasons, right? And the ultimate goal is you're looking for some type of change. And so even though work transitions can lead to happiness, often they can also lead to stressful or challenging times, especially in that short-term growth and change when you are going through that transition, right? And so really like only you can weigh the risk versus benefits and decide what's best for you. And I just wanted to share my journey of why I made this transition. So my transition really was a journey from academics to a private practice into an independent-owned private practice. And so I had a lovely introduction, so thank you. And I don't need to go through again, but essentially I did my residency up at Case Western Reserve University in Cleveland, Ohio, came straight down for my fellowship in urogynecology. When I graduated in fellowship then, I served as an assistant professor in an academic role for five years at USF. And I loved it. I was super happy. Anyone who knows me, I love teaching. I really looked like I really liked it, but after five years of that, I was definitely, I had an itch and I was looking for something different and different for me and for my family. So when I thought about it, I had this dream life that I wanted and I imagined in my mind, but I didn't know what that dream job would be that would get me to that dream life, that work balance, that feeling valued for myself, things like that. And so when I looked at this dream life versus dream job, I was thinking of the different transitions I could go through. And I knew and I looked into kind of these new faculty positions, right? I was already in academics and I knew that role and I was five years into it and I felt comfortable. And so I was looking at different opportunities with a university. Then I was looking at, okay, maybe join like a big, large multi-specialty. I have dear friends who are a part of these large multi-specialty practices. They're very happy. They have their own like internal network that refers to them and everything. And so I looked at some of those opportunities. I looked at joining a large hospital group, a large hospital. We have Advent and Baycare down here in Florida. I knew CCF up in the Cleveland area. Joining a large OB-GYN group, joining a smaller private practice group. But even as I was exploring these opportunities, right? They all work great in their own ways, but they all resulted in one thing that I would still be an employee under somebody else. It would just be a different name, a different company, a different practice, a different university, but I would still be an employee under someone. So as I realized, like I mentioned, all great in their own way, that wasn't what I felt like I was looking for down deep inside. That wasn't what I was looking for to kind of fulfill that transition, to make that leap for myself. I would still, if I took any of those roles, would still be an employee for someone else. And I realized that, you know, my time and my efforts would be expended for someone else's benefit, right? And oftentimes we do do that. And I was very grateful to give back. And I was very grateful to like be able to teach or to be able to serve and different things like that. And, you know, so I don't take away from that, but at that time in my life, I was looking for something different. And so when I was looking at these roles, I knew that I was looking for something that was a change in what I was used to. I was looking for a change than what felt comfortable to me. I wanted to have, I knew what I had to figure out what I wanted, and I wanted better control of my work-life balance. I wanted to feel valued for my work. But not only that, I wanted to be, I wanted to feel valued for my time that was gonna be away from my family and the things that I enjoyed doing. And so it slowly became apparent to me as I was looking at all of these different opportunities or all of these different work transitions, that for me, there was only one real option I wanted to explore. And that came down to really establishing my own company, you know, and have complete control of my time and my earnings, my revenue, and essentially then my value for what I was doing. And so I figured out, you know, what I wanted, what I wanted to do, but I still didn't know how, right? You still, you may have these ideas, you may have these lofty dreams and everything, but then you still might not know how do I do that, right? And so I really started thinking, you know, well, what makes Euroguide special, right? What's gonna make me special? What can I set myself up for? What opportunities can I kind of explore? And so I started looking and thinking like, how can I align myself with like other surgical specialties, right? Like, so in Euroguide, it's very much that I was aware of. It's, you know, a lot of academics, it's a lot of private, big private practices, but I saw a lot, like, especially in Florida, like there's a lot of these orthopedic, you know, practices or some urology practices that are, you know, physician owned or independent. And I wanted to kind of see how they did that and how did they establish that? And so I wanted to align myself with more some of these surgical specialists and see, you know, how can I use that to hospitals for my own benefit, right? And so before I could even go forward with that, I had to kind of understand, you know, these relationships, understand what hospitals are looking for, what type of relationships and contracts you can have with a hospital as a physician, especially as a surgeon. And more importantly, think about what can I sell for myself? And more importantly for us as a Euroguide specialist, okay? And so one of the things I like thought about, and one of the things I started realizing as I talked to other providers and other specialists and to hospital administration, is that, you know, we are, like us, as Euroguides, we are special. And I think we forget that often, you know? Euroguide is a surgical field where we perform complex surgical cases with implantable devices, okay? We use Y-mesh, slings, sacral neuromodulation. And the majority of our patients that we take to the OR are discharged the same day. And so really, like hospitals love that. If we can do complex surgical procedures and the patients go home same day discharge, that's a win for the hospitals, okay? And I think historically and academically, we're usually aligned with OBGYN departments, right? Which is appropriate. But when we're lumped together in these like women's health service lines, right? And I know you've heard this term and this term is used. I felt, and I do believe, that our true value isn't appreciated. I've been in conversations, I've seen where we get compared to, you know, the MFM consults or, you know, OB inpatient deliveries or the gynecological surgical cases and reimbursement. And we're told as a specialty, as a field, that we're not making enough money or that we then start losing OR time, you know? And we're not treated as the surgical subspecialty that we are. And so what I learned and what I kind of realized is that if I, and then we as Urogyne want to be successful, then we need, I think, we need to separate ourselves from this women's health OBGYN service lines when we talk to hospitals. And we need to market ourselves more as an outpatient surgical specialist with high volume same day surgeries. And that's what I, you know, essentially decided I needed to do to make this kind of dream job slash dream life of mine to make it happen. And so, again, I chose wisely the different hospitals that I reached out to. I tried to build connections with hospitals and align with them. And I, you know, essentially sold myself as an outpatient surgical specialist with high volumes of same day surgeries. I didn't, when I was looking to start my private practice, I didn't reach out to these like large tertiary hospitals, okay, not large academic centers or big hospitals with busy, you know, OB delivery wards. You know, I went to smaller, high volume outpatient surgical hospitals that concentrated on, you know, surgical outpatient volume instead of inpatient census. And I think that's the big key. And there are, you know, there are differences in hospital systems, even within themselves of like certain hospitals that they are trying to create as an outpatient surgery center or create as an outpatient surgical volume instead of an inpatient hospital. And so when I was looking to align with hospitals and to start this practice, you know, again, I targeted these certain hospitals. I approached them and I'm gonna talk about that. And, you know, I specifically for myself looked at these, the hospitals that had high volumes of bariatric robotic cases, because again, that's elective surgery, robotic, similar to what we do. Urology, obviously again, for similar reasons, I wanted to align with urology. Neurosurgery and ortho. A lot of those hospitals are used to implantable devices and they're used to the reimbursement with implantable devices when you come to ortho, neurosurgery. And then to be an elective outpatient, you know, surgeon, then I essentially positioned myself and set myself up when I talked to these hospitals to have that same worth and that same value as those service lines like ortho, neurosurgery, urology and bariatric. And those were the conversations that I knew I needed to have. So when I, you know, targeted my hospitals and I started looking and researching into, well, now that I know the areas or I know the hospitals and I see how I need to market myself and what's gonna make me special for them to want to align with me in this way. Then I wanted to know, well, what are the different hospital relationships? So how can I have a relationship like I see GI and ortho and urology and neurosurgery, like, you know, align with these hospitals to receive the benefits of these hospitals, but they still, these surgeons always still look like they're in control, right? And so these are the things that I had to find out that I didn't know when I was employed under academics. You know, I feel like in a very nice way, academics is often in this kind of bubble. And so I needed to see what were these other relationships that you could have. And so what I found out is that hospitals can have a lot of different arrangements with physicians. Obviously you can have a full-time employment, right? And that's where, you know, the physician is hired as an employee or under the hospital umbrella. You receive a salary, you're gonna receive their benefits, health insurance. You usually have like some type of salary with like productivity bonuses if you have a good negotiation there. And so obviously a lot of people do a full-time employment, right, with hospitals. But another thing you could do with the hospital is something that's called a PCA. Some physicians, especially surgeons or, you know, subspecialists can do what's called a physician service agreement. A physician service agreement is essentially where you're like an independent contractor, almost like a 1099 employee for the hospital where the physician operates as a contractor. So you kind of are independent. You are able to have some autonomy of your schedule, of your procedures, things that you offer, and providing these services to the hospital based on a contraction, some agreement that you sign. And oftentimes, you know, the hospital will provide some other benefits that are gonna be, like they might provide, and I've talked to like Advents, one that we talked to about this, like an office location, they'll provide staff for you. So they'll provide some of the basics to kind of have you set up for a practice, but you're responsible for your own benefits, your own taxes, you're essentially like a 1099. If you've ever hired a 1099 contractor, it's kind of what you are, but as a physician. So there is some positives with that agreement. You have autonomy, you're not an employee, you aren't under their umbrella for a lot of the control that some employees and employers have, but you also don't have the autonomy of often your office location, your staff, you might not have availability for control of your schedule, different things like that, depending on what they're able to offer and how incentivized they are to have you. And it's gonna be really based on that contractual basis and that agreement that you have. Very similarly, fee for service. So this is usually more set up for a group or a practice that may be already established, right? So if you have like a urology practice that is five urologists and they're looking to start operating at a different hospital, they may have some other type of fee for service where it's a compensation type basis based on what they're gonna kind of promise they're gonna bring to them, right? They're gonna promise they will see X amount of patients or do so many consults or cover so many ER coverages or different things like that. And so payment can be a subset payment that's directly tied to that, and it's some type of agreement. And so that's gonna be though, usually when a practice is already, a private practice is already established, they're gonna have that agreement, but that again is something that a fee for service type agreement or contract there. And then lastly, a lot of hospitals and especially hospitals when they're looking at surgeons, which we are, we are surgeons, they will do something what's called an income guarantee. So an income guarantee is essentially where a hospital looks at their geographical area and they see if there's something that is underserved. And you hear that and you think, oh, that's only gonna be in the middle of the country in one of these states or cities that aren't well populated and that would never happen in Tampa or never be in a busy city. But really like the more volume or the more densely populated an area is, it's all ratios. There has to be enough physicians for that area. And if you are a primary care or a primary OB-GYN, there's a large volume of primary OB-GYNs. So this densely populated area is probably compensated or the ratio of physicians to patients is appropriate. But as a surgical subspecialist in almost, I mean, essentially every city I looked into when I was looking into this, us as a surgical subspecialist, we, when you look at it, there is even in the most densely populated areas that maybe have large academic centers, like in Tampa, Florida, there's definitely URO guides there, but I was able to kind of come in and say, hey, this is an underserved area based on the number of patients in the area and the number of specialists for URO gynecology. And so there is like a certain number, there is this, you have to show that an area is underserviced for the patients, but essentially if that is there and that number is there, then a hospital can do what's called an income guarantee. And so an income guarantee is essentially where the hospital guarantees a minimal salary for a physician, usually for a certain period of time, so that the physician then can build a practice and the physician promises to serve the area for a certain agreed amount of time. This is something that a lot of surgeons can do to kind of establish a practice. It's great for startup because not only does it provide a salary startup, you can also negotiate and have startup costs for the practice and supplies aside from the salary. And so I'm sure you could probably figure that's what I did. And so I have done now two income guarantees for two different cities to build two different geographical locations. So essentially, and I apologize, I'm gonna go back real quick. Oh yeah. So I feel like I might've passed this one and I'm so sorry. I think I passed that somehow, but essentially, since 2022, when I left academics, this is what we have done. And we established Florida Urogynecology Specialists, which is a independent private practice. And it started out in 2022 with essentially three employees. So it's myself, I have a COO or an office manager, and then an MA. And we have one office location. And then in 2023, so last year, we opened up a second office location and added a second provider and grew for our employees to kind of help with that addition. And so we had eight employees. So again, myself, my office manager, COO, and MA, we hired a PA and then four staff members to help. And then now at the end of 2025, now we've grown to two full-time office locations with three full-time providers and 11 total employees. So again, myself as the physician, I have two full-time PAs, I have my office manager or COO, two MAs, one for each of the respectable locations, and then five staff members. And so to start from the three of us to now within two years, be able to grow to two office locations, 11 total employees to serve two areas of patient care has been a really exciting and remarkable journey. And that's kind of where we're at. And it's funny, somehow that got skipped over, but so going back through, essentially that's what I did was called an income guarantee. So getting to the nitty gritty of it, an income guarantee, like I mentioned, it's gonna be more aligned with a hospital who wants to bring some type of surgical volume to a hospital, right? I mean, there has to be an incentive for that hospital, but because of Stark law, they can't say, we'll pay you X amount, you have to do this type of these surgeries here. So it really is an agreement that essentially this hospital's supporting you, this hospital's saying, we're gonna support you to get started, to start your practice, and you're gonna agree to serve, see patients in that specific area. It's usually based on just zip codes, okay? So it's based on a zip code area that you're agreeing to see patients with. It's usually like a specific ratio of duration. So usually they will give you a salary and support for one year, and then you agree to serve for two years, or maybe salary and support for one year, and you agree to serve for three years. And again, you are not an employee, you don't have any type of, you don't have any type of agreement to certain number of cases, certain volume of cases, certain patients to admit to that hospital. You don't even, I mean, you do operate at that hospital because we need to operate at a hospital, and it's usually the one that you've had discussions with, but you don't have to even agree to operate at that hospital. This is essentially the hospital saying like, this is the underserved area for your specialty, we wanna bring it to serve this area for these patients. And it's a mutual symbiotic relationship where if you are able to operate there, the hospital benefits, and then obviously you get the benefit of the hospital supporting your startup and your growth. One of the things that's nice, like I mentioned, is not only does it give you a salary, a guaranteed salary, monthly salary, there also can be negotiations for other startup costs. So the first year I did this, I really didn't know what to ask for. And I asked for, I mean, obviously I knew the income guaranteed, right? So I had my income guaranteed, which for me, I am the breadwinner of my family essentially. And so we were very dependent on my salary for our life, our livelihood, our mortgage, our cars and everything. And so to make that leap from academics where I had a stable salary and you know what you're bringing in, to make that leap to go independent, it was a very helpful to have this income guarantee so that, okay, I know it's gonna be hard. I know there's gonna be highs and lows. I know we're gonna have to, and I'm gonna get into it, take out a line of credit and go into debt for various reasons. But at least we know here for this year, we're gonna have this salary income guarantee. We're gonna be able to pay our mortgage and things. And I'm gonna be able to take care of my family as I make this transition in life. And so the first year when I did this, I just really had an income, like the salary guarantee and I had a little bit of supply to help, like a little bit of supplies that would help. But then really I learned from that. And then the second time when I moved to a new geographical area to open up my second office, I was much more well-versed. I understood the process. I was able to ask for a lot more and present myself in that way. And so I was able to get employee salaries, employee benefits. We got a lot of furniture in the startup. So we had a startup cost for some furniture to be able to get. We had money for marketing for the first year. So definitely depending on the relationship, depending on what the hospital's looking for and things, this really can help. And that's what it writes here is that, if you're able to do this, then the guarantee can help cover not only your salary, it can help cover initial expenses, such as office setup, employee salary supplies and et cetera. And it just really helps alleviate that financial pressure, right? That financial pressure, especially in those early stages when you are trying to build a practice, you're trying to do your workflow, you're trying to understand how to even bill and get collections and call insurances and get authorizations, right? All of the things that we are physicians, like we can figure that out, but we need time to be able to figure that out. And if we are, so to be able to have that cushion, that availability to where, okay, like for the first year, I scheduled all my own surgeries and I was able to do that and really learn that process so that then I was able to, now like almost three years into it, right? I have two full-time surgery schedulers for me. So, it definitely helps that cushion, helps that transition. And that was one of the huge things that I think I was unaware of when I was in academics that was out there. And that's essentially what the last sentence there says. So, when you think about, or if you're thinking about an income guarantee, it's really important to target a hospital that is in the location or the hospital, but more importantly, I think a location that you desire to practice. Because like I said, you're not necessarily committing to that hospital, but you are committing to that location. It's usually a geographical area, they have it on maps, like these are all, this is all like very down to the numbers. And so you want, and it might be somewhere too that like you wouldn't even have to move. You might be actively practicing in a city and you might be able to like move right next door. You might have a non-compete, but you might be able to move next door and hang up a shingle and start a practice and have a hospital help back you up. Even though you may have like a group or a practice or even a large academic center right there, it's really comes down to the numbers and the ratio of those geographical areas. So once you kind of know that area that you wanna commit to, then you wanna like send a letter or you wanna send an email and try to get some type of meeting. There's like, you know, these different people in these hospital administration and it's, you know, usually you have like a physician recruiter and then there's gonna be somebody who's called like the VP of physician recruitment. They're like a little higher. Sometimes it's called the VP of like physician relationships, you know, or physician liaison or something like that. And then you're gonna have the CEO, right? And the CEO is really who's gonna make that determination and that decision. And so when I was looking, especially for my second office, when I was looking to kind of move back to an area that I had to move out of and my family wanted to move there, you know, I created this email. It was essentially a cover letter email, just essentially, you know, describing who I am, that I wanted to come back to that area. Here's my track record. Here's what I've done. And I cold emailed it. I essentially just like Googled, got email addresses, just started emailing it to like a bunch of CEOs in the area kind of all of the physician recruitment people I could find and, you know, until I was able to get that meeting, right? So you really need to just talk to people and get that meeting, get the meeting with either the VP of physician recruitment or get that meeting with the CEO. Once you get that meeting, then you're going to have to be prepared, right? You're going to want to be able to pitch yourself. You're going to want to be able to show your value and your worth to that hospital. This goes back to a lot of what I talked about in the beginning, okay? And so, you know, I printed up, we had a vision plan. I knew what I wanted to kind of demonstrate and bring to that area. And so essentially, like I mentioned, you know, you're going to have to have that pitch, but on top of that, you're also going to have to have a perform up. You're going to have to show that, okay, I understand these values. I understand these numbers, and I'm going to demonstrate my revenue and demonstrate my growth so that your investment is not wasted, so that your investment in me and in my practice is not going to result in my practice just capooting out, right? I'm going to show you this growth. I'm going to show you how I'm going to have this revenue, these collections, and I'm going to stay in the area and we're going to provide service in the area. And when I provide service in the area, that directly relates to money going to your hospital, right, because I have to operate somewhere. And so that's really kind of what that conversation is going to be about. And so when you have this meeting, you know, you don't have to, but it's good to have an understanding of what a performa is. You know, I've started from knowing nothing to performas to knowing everything you could possibly could. There's times in my life where I've seen cross-eyed performas as we've gone through them. And essentially it just, you know, there's a variety and variations. This is the one that we used. And centrally, you're going to show your cash collections up front. You're going to have your one-time expenses that you're going to be asking for. You're going to have your reoccurring or kind of incremental expenses. These can change month to month, but essentially they're going to, you know, be variable. You're going to have your contingent ones, the ones, these incremental expenses that are monthly that you know are going to be there, like your rent. You're going to have your total incremental expenses and then your net income. And then the cumulative, like, you know, when you subtract and see, are we under, you know, or are we black, right? Are we red or are we black? And so this was kind of like, it just demonstrates kind of what a performa would look like once it's filled in. Obviously in an Excel, it kind of calculates for you then, like as it needs to add up and everything. And then if you have a one-year kind of income guarantee, you want to show that by year two, your collections should equal kind of what your monthly cost is, right? So if your monthly total incremental expenses are about 78,000, by year two, you want to show that you're making about 90,000 or something like that in your collections. So again, you can show that I'm going to cover this, I'm building a sustainable practice, and this is going to be how we're going to do this. So getting into, so that's kind of like the how, right? And like I mentioned, at this stage now, since 2022, we have two full offices, it's under my LLC, we have three providers, we're fully staffed, we're looking to grow and to build, not build, but to grow and have a third office. And so we're definitely, we've done this now twice, and it definitely is a sustainable model, but there are important logistics, important things you need to know along the way. And so early on, there's three important people you need, and you need to have somebody who's going to be your like right-hand man or right-hand woman, right? I say COO, but, I mean, because you're going to be the CEO, you're the CEO, but you need to have a COO, and it could be either somebody who's like a prior office manager, they've opened up other practices, they've been intimately involved in other medical practices, maybe a nurse that you know, or you trust, who can kind of segue into the more administrative side. For me, I was very lucky because my husband is that person for me, and he has his MBA, so he understands the business side, he's also a physical therapist, so he understands the healthcare side of it, but it could be anybody, and you don't, but it's just very important that that person has to have that shared investment of you succeeding, right, that shared investment of the practice succeeding. And I think that's really important. Early on, early on, it can't be somebody who just looks at it as a job. Right now, yes, I hire people, and, you know, there is a job, but I needed people who were invested early on. It's really important too to have a good healthcare lawyer, not just a lawyer, I think it's important to have a good healthcare lawyer. I, again, got really lucky, I was introduced to this really good healthcare lawyer early on by a dear friend, and this lawyer has helped me, you know, in different situations that, either with contracts or negotiations and things like that, and to have somebody who understands the healthcare laws and understands different things, I think is important if you're looking to do this. And then you wanna have a CPA, again, a CPA that's gonna help you on the more finance side, on your payroll, on your taxes, things like that, because, and again, to have somebody who's going to be aware of private practice and medical practices and ownership, right? So somebody who understands like being an owner and what that means, it entails. You have to obtain your LLC. So my LLC is Allison Weinman MD LLC, but then I have a DBA doing business ads, Florida Urogynecology Specialist. So when we write checks, what's on our credit cards, our business cards, everything, it says Florida Urogynecology Specialist. Again, my lawyer set that up. You also are gonna need to obtain an EIN, so it's an employee identification number. This is what makes you a true company, right? And again, my lawyer set that up. You need a lawyer to do that, right? Next, you need to find office space. In order to get any type of credentialing with any insurances, you need to have a physical office space. You need to have something that mail can be sent to. It can't be a PO box. It has to be a physical space. And what I would consider and what I did early on is I aligned with other specialists, especially other surgical specialists, because things are expensive and you're trying to look for ways to not increase your cost, increase your debt. And so I aligned with a plastic surgeon early on. It was great, because the plastic surgeon, they're usually in the OR two, three days a week, and then I'm in the OR two days a week. And so the day that he was in the OR, I was in clinic. Vice versa, the days I was in the OR, he was in clinic. And so that way, we're sharing the space. I'm not paying a full five days a week rent, and it saved money. So my first year, I did this for the first full year, and I was two days in clinic, two days in the OR, and then one day of admin and marketing. And again, I did this for the first full year until I was busy enough to hire a part-time PA, and then I was able to rent office space for five days a week and kind of justify, because she was bringing in some revenue, and somebody could be there on the days that I was in the OR. So logistics continuing. It's really important to obtain either a bank loan or a line of credit. I feel, and what we did was a line of credit. I think that should be preferred, just because then you're only borrowing what you need, instead of having like a large bank loan that then is gonna develop interest, and you're gonna have to start paying on it. And so a line of credit, it has interest, yes. You're gonna have a limit on it, yes. But that way, it's almost like an extended credit card where if you can take out large lumps, if you need to tap into it, but then you can pay it off, you're not penalized for paying it off. And so depending on the fluctuations of your collections, the fluctuations of your month, different things, I think that is important. Now, when there's a line of credit, though, the bank is essentially, they're taking a risk on you. And so you really wanna have like a lean business form to kind of present to the bank. And again, this is something that your CPA could help you with. You could fill these out. And I think that's where a CPA is very helpful into kind of presenting yourself as a viable company, as a viable business that the bank's gonna want to invest in. They're gonna want a long-term investment with you. You need malpractice, right? So I use MagMutual. There's gonna be at the end, I'm gonna show you some of these kind of websites that I use that have a lot of patient or a lot of these physicians, private practice use MagMutual. You're gonna need to get credentialed with insurance carriers. I would just go with a credentialing agency. There's a variety of ones. You can look into it. There's a website, again, that I can show you that's gonna have references for your certain states. And then you need to get credentialed at a hospital or a surgery center. And there's gonna be negotiations there. Are you gonna take ER coverage or are you not? Are you doing inpatient consults? Can you promise the PA in my OR so that I don't have to take my PA there? Different things like that. And again, can touch base on those in the questions. So logistics continued, right? You're gonna have to buy furniture, medical equipment, supplies. Again, this is where an income guarantee is nice to kind of figure out these steps, kind of get your basis for what you're gonna need with Henry Sheen, which is like the big medical, the medical supply company, things like that. Early on for my systole and my urodynamic, I did kind of a rent to own with them. So now I have my own system, my own urodynamic, but I rented it for a while. There's some companies that you can actually rent even someone to come and run your urodynamics. I was lucky I had my MA, she was trained. But there are definitely some ways that you can work around so that you don't have to do these big investments for these big, large capital equipment. You're gonna need an EMR. A lot of private practice, you're never gonna be able to do those big, large corporate EMRs, but we use eClinical, a lot of patients, or a lot of providers I know use eClinical. I can touch base on that. Phone systems, fax systems. Like when I was at USF, you had these big phone systems that those phones and you had the different numbers you can call in and everything, or you had big call centers. And funny, if you look at those, they're expensive. And so we use this company called Spruce. Spruce, and there's another one called Grasshopper. I'm gonna touch base on it in a little bit, but it's been very helpful. It's really nice how you can implement it to a practice and make it look very professional without having to have a huge investment. You're going to need a billing collection company. You're going to need to hire staff. I'm going to touch base again on a company called Edge or OneEdge where you have virtual assistants. So since I started, I've always had a virtual assistant that has been out of the country. Each one that I've used, they've been in Pakistan, and they're lovely and wonderful and so helpful. And so I want to talk a little bit about that. One of the things about hiring staff, I would recommend whenever you can, and especially early on, hire part-time. Not only does it, you know, you want to pay people for only when they're working, but it also saves in benefits because benefits are really expensive. And so if you have part-time, sometimes that can help with that cost for you until you're up and running and able to provide those. You're going to want to set up payroll and taxes. That's, again, going to be with your CPA. And then create a logo, a brand, and a website. And I used 99 designs and then also practice. So OneEdge, this is the company. It's based on this private practice Facebook group. It's an excellent source of information. I have a screen link for it, but they provide well-trained, experienced employees. They provide a matching service. So they line up candidates. You kind of talk to them, tell them what you're looking for. They provide candidates for you, and then you interview them. Each candidate is then chosen. Once you have a candidate that's chosen, then Edge, the company, trains them in your EMR and insurance verifications, eligibility, registering new patients, scheduling new patients. They get them trained for about two to three weeks until they're up and ready to kind of start working for you. One of the things that's nice as a private practice too is that Edge provides the salary and benefits for this employee. They also take care of their PTO. And so essentially, we pay a fee for service. So we pay a monthly service fee to this company. They take care of the benefits, the salary, the PTO, all of the administration work for our employee. And then because we're paying this fee service, it's a write-off. It's a tax write-off from our bottom line. And so it's a really nice setup. The other thing that's, you know, it's sad, but is that the ratio of the American dollar to the Pakistani dollar is different. And so the cost is a little less than if we had an in-house person who was answering the phone. And then they're all really well-qualified people. Like most of them that I interviewed, they're all professional already. And, you know, they're pharmacists, physical therapists, nurses. We even interviewed an MD and, you know, they openly say like doing this, I make more money or have a better lifestyle or a better opportunity working virtually for you than I would if I would go to the local hospital or go to the local pharmacy. So this is a picture of Noor. This is Noor. She works for with us and she's been with us for over a year. She lives in Pakistan. She's a physical therapist. If somebody calls my office, she's the one who answers. She's our front line. She has a warm, welcoming persona and she's wonderful. So she answers the phone. She navigates patients. She registers them. She schedules new patients. And like I said, she's lovely and she's been with us for over a year. So Spruce, as I mentioned, this is our phone service. This was a very interesting thing that I learned too, is that, you know, this one, and I think the other one is Grasshopper, that's very helpful. And essentially, you know, instead of having to buy large phone systems, this is an app. It's an app on your phone. It's an app on the computer and it's all HIPAA compliant and it goes directly to my phone. So essentially it's, you know, you pick a phone number. This phone number is what you put out there is like your office, your physical office phone number. But when patients call that, it calls through this HIPAA compliant service and it goes directly to myself. So I can be anywhere and get numbers, you know, get a phone call from a patient. I can call a patient from our office number and I just have to go through the app. And so what's nice about that is that then because of that, multiple people can be on this phone line and they don't have to be physically at our office, right? So even Noor, my virtual assistant over in Pakistan, she answers the phone for patients who are calling into Florida urogynecology specialist, but she's answering in Pakistan, even though the patients are calling the number. You know, you can have multiple phone numbers. So now that I have two physical office locations, one in Lakewood Ranch, Sarasota area, one in the Tampa area, we have two numbers for those. But both of those numbers go through Spruce, go through a HIPAA compliant phone system and go directly to my cell phone. And I'll just see it come through and it'll tell me this is from Sarasota or this is from Tampa. So again, from my own cell phone, I can receive patient calls, faxes, things like that. Now I'm running short on time. So 99designs is a very cool website. That's where I got my logo for both Florida urogynecology specialist and Emory's Med Spa. It's a med spa practice. Again, wonderful website, wonderful company, been using them for three years. They specialize in medical management. They also do search engine optimizations. They design the website. They run my website. I can talk about that. They also have alignment with a lot of the companies we use. The other thing is like leveraging industry partners, leveraging industry partners for making educational videos. This is like a little video that may play or may not. So I didn't have these videos on the website that I didn't pay for. I didn't have to set this up. It looks professional. I love it. Patient education. They even have like little cute movies in it and everything. And so really, really nice videos, marketing, things you can do by leveraging industry. Again, owning your own company, some of the advantages. So one of the things that my husband and I are doing is we are paying our kids. You can pay your children up to 12,000 a year per kid. Each kid or each is a tax write-off. So again, when you own your company, your goal is to kind of lower that bottom number to a lower tax bracket. What we're doing is half of what we can pay for each kid, we're putting into a Roth IRA. And that's going to hopefully over time create generational wealth for them. The other half, we're going into a college fund over in Florida. They have these really nice college funds so that, and the kids are working, they're working, they're cleaning, they're healthy. They are, you know, filing paperwork. They open up mail for us. They're all technically models on my website, if you ever go to it. And so, you know, they're working, they're learning what it means to kind of have an own a company. And then we're putting in a college fund. And over time, again, if we own this company for 10 years, it's 12,000 a year for 10 years, that might be 120,000 per kid. We're able to kind of have for them that they're going to feel that worth. They're going to know that they worked for. Obviously we have other tax write-offs. You know, we lease cars, that car lease goes because we drive back and forth. Gas when you go to work, you know, you can write off. One of the positives is you can imagine determining your own clinic schedule and volume, surgical center opportunities when you are independent and not under some type of corporate umbrella. And then you can align other interests, interests that you may have with your company. So I over time really got into not med spa in the sense of like Botox and fillers. I don't do that, but I was really looking for a med spa for sexual health. I was looking for empowering women to feel and look their best at any age. And so, you know, Dr. Krem did a wonderful lecture on the Empower platform. It's Morpheus 8, which is microneedling and radio frequency for the vagina. So I do offer that. Again, it's not something like I, I'm not looking to add much more, but it has been nice to kind of implement that and then like have added bonuses of having those discussions and helping women. You know, I do, I, I love personally skin medica and I love like, you know, vitamin C for, you know, skin suticals. So because I have this med spa, then now I can get them at cost and my friends benefit. So it's like a win-win for me with that. Two websites that I think are super important is Physician Sidekicks and Private Practice Physicians. Both of these have been a wealth of knowledge, especially this Private Practice Physicians. You can Google it. You can look in information. If you're just kind of dabbling, thinking about maybe starting this there, you know, so many people that are willing to help and answer questions. Quickly now, some of the challenges, obviously insurance contracts are very, very tough when you are independent. You are not going to have what you're used to for your reimbursement. So for that, I have to make up in my volume. You know, you have a decrease of your collections. And so you have to make up for that in your volume. You know, as you can imagine, you're putting out fires every day, every day is hustling and, you know, you can't really turn it off when you own your own company. I remember when like I was at USF and, oh, I got my notes done. I filled out all my med student evaluations. I crossed my teeth, dot my I's. I can go home and relax, right? I can zone out. I've done all my work. When you own your own company, and especially in this growth phase, you know, it's really hard to turn that off. You're always thinking, you know, how can I implement this? Or how do I have a better workflow for, you know, these patients? And, you know, you're constantly trying to navigate that. Last thoughts. So timing. For me personally, I don't think I would have been able to do this right out of fellowship. You know, they really say it takes five years to feel comfortable as a surgeon. And I feel that way. And I think in order to have that confidence and to go out without any safety nets and be on your own, like I said, I am completely on my own. I don't have a partner right now. I operate with PAs that the hospital just gives me. And I'm doing three robotic sacrocopal pexies a day. And, you know, so I've really had to like fine tune my efficiency, my, you know, my surgical etiquette for, you know, to optimize things. And so I think, you know, again, I would have had a hard time right out of fellowship. Facebook groups are really helpful. Start asking your employee contract information and collection information if you're interested in this. And lastly, hire a team with a shared vision for you to succeed. And so these are all of our employees. As I mentioned, that's Nour. These are nurses. These are my two PAs. This is, again, another nurse. And so, and these are med students. So I have med students that are with me and they're my medical scribes. They're pre-med. They're trying to get into med school, but they're my medical scribes. And I love them and I teach them. And so you can still teach. You can still do different things. Okay. Sorry. Questions. Thank you so much, Dr. Whiteman. We have so many good questions for you. So definitely want to give time for that. So as a reminder, just use the Q&A feature in order to, in the Zoom webinar, in order to ask the questions. So a couple for you. In the beginning, it sounds like you rented your dynamics machine. How did you kind of decide which equipment you were going to rent versus buy off the bat? Yeah, that's a really good question. So I, you know, with the Eurodynamic machine, I actually did, I did purchase that, but the cystoscopy machine. So I use a cystoscopy machine where it's, it was called congentics. It was labory where you had a sheet. And so you had a disposable part and, you know, so that disposable part you need to do in order for the machine, you know, to do the cystoscopy. And so I had an agreement with them. It was a three-year agreement where we, we would use X amount of sheets. And then by the end of the three-year agreement that I would own the machine, which is like the full tower, the cystoscope, all of that. And so, again, that was, you know, you need to have the sheets anyway. And like, there was kind of when I, until I got busy enough, there's a higher volume of numbers, but we would just kind of store them and stack them. And, you know, and then now at this stage, I own the equipment just from doing the cystoscopy that I was getting reimbursed on anyway. And so essentially the equipment I essentially have now, and I still have to purchase the sheets, but that's it. Now with the, you can rent to own your urodynamic. And I looked into that, but what ultimately it was, you would have ended up paying a little bit more in the long run. So for me, it just made sense at that time. I used my line of credit. I knew, I knew I needed urodynamics. I purchased that machine with my line of credit. Got it. And then what is the typical income guarantee to negotiate? And what is the typical cost of a startup? Oh gosh. So I think that's going to be very dependent on location and on, you know, the cost of living. So when you go to this, you know, obviously you can't just like make up willy nilly numbers. They have to be kind of based on the MGMA data. You have to, the one thing that I always held myself to was to, you know, the 85th percentile. I always held myself to like comparable to urologists, you know, for urogyne it's really tough because we don't have a lot of subspecialty information. I think it's great that Oggs is always trying to put out more information, but the Oggs data is really skewed, right? It's skewed towards academics. And so when I presented numbers and I presented information, it was definitely more geared towards like a urologist or towards like, you know, different surgical subspecialties. So, you know, it's, it's tough to say. So an income guarantee essentially could be what you feel that you need. As long as you show like the performa and you have the breakdown of what, what each cost item is going to be. And it's not like they just give you a check, right? And you walk away. This is an ongoing relationship. It's a monthly kind of receipts and tally where you say, okay, this month I want my salary to be 400,000, right? So break that down monthly. What my salary is going to be. I'm going to pay, you know, Dr. Y I'm in this, I'm going to pay my staff X for salary. Supplies are going to be 2000 a month. And then I have to show receipts. I have to show them my payroll receipts that, that money that I said I was going to give me, my staff goes into their payroll, right? And then we have to, I have to pay taxes on that. I have to show them receipts like here from Henry Sheen or here from labory. Here's the catheters I bought. Okay. And then, you know, so it's a lot of work. This is why you need that. Like my husband did a lot of this, right? You need somebody, cause you're busy operating. You're busy seeing patients. You need somebody to oversee that, but it's stuff you can do. It's all really easy when you think about what we've done in our lives, right? We're physicians. Like we've, we've conquered a lot. And a lot of this is just the busy work. And that's where the income guarantee was really nice to provide that cushion. So you could work through that. Yeah. Did the hospital support the salary of the COO and the staff initially for whatever period you negotiated? So not for the first year again, cause like I said, I wasn't knowledgeable enough myself. Right. So I only asked, I heard income guarantee. I thought, Oh, it's just for me. But then as I learned and everything, then for the second time, the second round I did it. Yes. I got a salary for my CEO. Oh, I got salary for my staff. Got it. Um, how do you manage, um, uh, dividing your time between offices and then also how do you manage post-op patients given that the offices are not close? Yeah, perfect. So my offices are about 40, well, about an hour away. Okay. So it's not unmanageable, but absolutely that's, you know, one of the things that again, I migrated to is the majority of my patients go home same day. So, um, you know, I would say 85%, 90% of my, even sick or copepaxes go home same day. Um, I spend an insane amount of time counseling ahead of time. And so it's a lot of setting up that expectation. It's, you know, obviously if a patient's sick enough that they need to be admitted, then that's coordination event. Those are things too, that, you know, you have those conversations now being in private practice and being on my own too, you know, I, I, there's been a couple of patients where I've said like in my head, gosh, when I was at USF, I would have taken you, you had, you know, an X lap and a LAR and blah, blah, blah. But I would have taken you back and take, you know, but now I'm like, ah, gosh, I think you need a, you know, a pessary is going to be the good option or go to the tertiary. Like, luckily I have USF still, I have an academic surgery center. Right. So again, things that like, I probably would have taken on, on my own, you know, I have to be cautious now with them. Right. Because I want to set that patient up in the safest way. I want to set that patient up in the most optimal manner for their surgery. So even though in my hands, I might trust myself if I know they're going to have an extended long stay at the hospital, I'm going to graciously refer them to a more tertiary center. Got it. What do you feel is your best utilization of your PAs and NPs? Yeah, good, good question. So absolutely seeing patients in clinics, you know, I think some, you know, I know a lot of orthos who have their PA like in plastics, their PA like follows them around like a puppy dog and they go into the OR with them and they go around with them. And, you know, and I just, I don't know. And so my PAs, I, they're essentially like independent practitioners. They are independent providers. I love it when a patient wants to see them and they don't say like, am I going to see Dr. Wyman? You know, like I love when the patients look at them as their providers. And so they do a lot of the initial workup, you know, a lot of the pessary patients, I see recurrent UTIs, a lot of my OABs, a lot of the prolapse patients, they're doing the initial workup. And then I do a lot of what we call bladder test consults. So essentially I see like, you know, they might see a new patient do the exam. And then if a patient's for surgery and if they need a uro or they need a cysto or they, you know, want to try a pessary, but now they're ready for like a surgical consult. I do a lot of surgical consults. It's kind of like a revisit of the options. I talk more extensively about the difference of surgical options. If I feel the need, I'll repeat the exam during that time, things like that. Did you run into any issues with the non-competes when you were going through this process? Yes, absolutely. And that's right. Yes. So when I left, the USF has a pretty, you know, they had a two year non-compete for two counties. So I had to move. I moved my whole family. We moved about, that's why we went down to Lakewood Ranch, the Sarasota area. And then it was perfect because that was, it was a one year income guarantee with a two year commitment to that service area. So I knew no matter what, I had that mobility if I needed it. But at that point, I've grown such a lovely practice down there that, you know, I want, I hired my PA, she's working great. And then two, like someone asked how I divide up my time. So I do robots on Tuesday. Every other Tuesday, I'm either doing robots in Tampa or robots down at Lakewood Ranch. Every Wednesday, I'm in clinic in Tampa. Every Thursday, I'm in clinic at Lakewood Ranch. And then Fridays, I have my like surgery center outpatient. And again, I go every other, so like Tampa or Lakewood Ranch. So and then Mondays are my kind of admin, my catchall, my marketing kind of days. Great. We have so many questions coming in. We're going to try to get them answered in a separate feed and get sent out. I want to, on behalf of AUGS, I want to thank Dr. Wyman for this excellent, riveting webinar. Be sure to register for our upcoming AUGS educational webinar on February 19. Join Dr. John Stoffel as he presents a webinar entitled Chronic Urinary Retention Causes Diagnosis and Management. Also join AUGS for this exciting new four-part webinar series designated to educate and empower physicians with financial tools and insights we need to prosper in 2025 and beyond. The first webinar will kick off on February 5, titled New Year, New Fresh Start, Financial Planning for 2025. Follow AUGS on Twitter, Instagram, and check our website for information on all upcoming webinars. Thank you all for joining and have a wonderful evening. Thank you so much. Thanks.

urogynecology

private practice

hospital relationships

income guarantees

business plan

virtual assistants

operational efficiency

team roles

non-compete clauses

entrepreneurial approach