Good evening. Again, I'm Dr. Susan Barr, and I'm the moderator for tonight's webinar. The webinar is entitled, Finding Efficiencies and Enjoying My Practice, and is being presented by Dr. Ryan Stratford. Dr. Stratford is a board-certified physician in female pelvic medicine and reconstructive surgery. He completed an undergraduate degree in finance at Brigham and Young University, and has worked, I should say, but then he saw the light. Instead of working in finance, he has worked his career as a physician. He completed a master's degree in business management at the University of Chicago Booth School of Business, while completing a medical degree at the University of Chicago Pritzker School of Medicine. Dr. Stratford completed residency training in OBGYN at the University of California, San Diego, and fellowship training at Scott and White Memorial Hospital with Bob Schull as his first fellow. He has served as the treasurer for AUGS and is president of the Maricopa County Medical Society. In these roles, he managed large budgets and sought effective ways to lead large organizations. Dr. Stratford started in private practice in urogynecology in 2005, and has successfully grown the business to include over 15 employees and providers, which also includes residency training for the University of Arizona. Unfortunately, Dr. Stratford is having internet difficulties tonight, but he has pre-recorded his presentation on video format. So as soon as we conclude this Zoom, AUGS is going to email participants the link to Dr. Stratford's video, as well as his email, so that participants are able to contact him and ask their questions. We would like to thank Dr. Stratford for his efforts and in recording the video, and we look forward to viewing it. Our next webinar is titled Establishing a Productive Resident Research Program, and will be presented by Dr. John Shepard on August 12th. Thank you, and have a good evening. Hello, I'm Dr. Ryan Stratford. It's a pleasure to be with everyone. I know it's an unusual way to meet, but we're becoming familiar with this way. We all are now having to meet a lot more frequently and over video conferencing, and so this will hopefully be a little more comfortable than it might have been otherwise, because we've become more familiar with it. I'm going to talk today a little bit about finding efficiencies and enjoying my practice. I am a private practicing urogynecologist, and have learned a few things that hopefully I can share with you that'll be of value. I don't have any disclosures except for my participation in a few registries, and I have done some legal work for Ethicon as an expert witness on some cases. I know many of you will resonate with these pictures. There's days when I leave the office and I think, what just happened? Things just didn't go well, and I know that that can make life miserable and frustrating, and we sometimes wonder what could we do to make things work better, more efficient? How could we make our days a little bit more exciting? Well, there are a couple of things that we like to have every day. As I think about what would make my day great, some of the things that matter to me most are running on time. I get really anxious and frustrated if I know patients are waiting in the room for me for a long period of time. If all the patients show up on time and all their pre-appointment paperwork's been completed so that I can see them at the time that was allotted, that makes me happy. If patients give me some feedback, that helps my day go well. I also like if my staff is happy and upbeat. Sometimes they're having a bad day for various reasons, or things aren't going well because patients are frustrated. So how do we create these types of days, and how can we, we can't obviously avoid all the pitfalls and unexpected events that occur on a day-to-day basis, but how do we try to make it so that it's more likely to not have days like this? I'm going to focus most of my comments on some ideas that came out of Harvard Business School. I have some training in my background as an MBA, not at Harvard, but at the University of Chicago. But as far as it relates to management, there's been a lot that's been written about this. I'm going to talk a little bit about how we can categorize ways of improving what we're doing. And we improve by innovating. So we're going to talk about innovations. One of my favorite authors on this is Clayton Christensen, who's on multiple boards of Fortune 500 companies, has been a professor at Harvard for many years, just passed away this last year. So he said there are three types of innovations that affect jobs and capital. Empowering innovations, sustaining innovations, and efficiency innovations. So we're going to talk about each of these three types of innovations, and at the end, if there's time, I'd like to hone in on a fourth one, which happens to be what Professor Christensen spent most of his career dealing with, and that's disruptive innovations. So let's go through each of these, and we'll talk kind of what I think they mean. So first, let's talk about empowering innovations. So empowering innovations are things that usually come from employees. So one of the, an author of Driving Innovation from Within, Cagan Krippendorf, said this, employees have historically been the primary drivers of innovation in society. 70% of history's most transformative innovations have come from employees. Without employees, you would not have the internet, email, mobile phones, MRIs, or solar energy. So if we empower employees to innovate, to think of ways to make things work more smoothly in our office or in the operating room, we are able to then find better ways of doing things without we, ourselves, having to come up with all the ideas. And I think that the key there is filling, helping employees feel empowered to come up with new ideas and then to engage them, not only bringing those ideas to light, but also immediately trying to respond to them or putting those ideas into place will give them the confidence to continue to provide them. How does that happen? Most of the writing in the management literature talks about the culture that you create, and if you have a culture that encourages employees to innovate and to come up with ideas, you'll be much more successful in receiving ideas and being able to elicit those from employees at every level. So let's now talk a little more in detail about how we can empower. There's three important ways to encourage entrepreneurial thinking. One, allow people to collaborate across silos. I see in a lot of offices, they'll organize offices by work type or similar responsibilities. They'll have the front office people kind of interact a little bit, the back office people may interact, the providers interact, and they have all these silos within the practice. And if they don't collaborate across those silos, no new ideas will come out of it. So providing opportunities for them to collaborate across silos is critical. Provide some innovation resources, which take both time and money. In our office, we dedicate about 30 minutes to an hour a week for all of our staff to collaborate and we'll bring ideas forward and present them to the whole group and each sub-population or each silo is able to bring ideas forward and then discuss them. So that takes time, it costs money, we're paying all of our employees to be in a meeting, and we're not seeing patients during that time, but it has provided tremendous help in encouraging our staff to feel part of the team and to innovate. We allow people, you have to allow, number three, allow people to get credit for something. If they try something new, you want to give them all the credit for what happens because then it empowers them to want to keep coming up with new ideas. One of the most important things you have to do though is recruit talent that will want to innovate and then develop a culture that will encourage them to do it. So as I mentioned, a couple of ideas that you may consider as ways to increase the innovations and empowering people to innovate is by having weekly staff lead meetings, staff outings, group discussions, there's online forums that you can create, very easy to set those up. Sometimes just walking around with the staff, remember talking with them, asking them questions as you're seeing in between seeing patients. I know that many of you will probably experience that just when you're trying to do your daily work. Management is doing things right and leadership is doing the right things. Sometimes we spend too much time managing and not leading and there's times when it may seem like it's a good cost savings or there's some benefit but at the end of the day what matters most is doing the right thing. So let's talk a little bit about sustaining innovations. So we talked about how you have to, if you empower employees, you can come up with new ideas but you can also continue to come up with ideas that will sustain what you're already doing and there are a couple of different consulting firms have given feedback about this. They try to help companies to do this and some of these include, for instance, Deloitte and Touche, they seek sustaining innovation to seek to improve existing services. The idea behind this is try to continue whatever product or service that you already have and making it more meaningful or better. Innovation that happens on an incremental basis often in response to the customers and market demands or improvements in technology. Maintaining open channels for patient feedback and communication will allow you to collect data and how you continually improve and provide greater value to your patients. Most sustaining innovations will come from patients. So how do you elicit patient feedback? That's a tough question and I think for some doctors that's uncomfortable. They don't want to ask patients these questions. They want to just help them solve their health care problem but it is important to ask for feedback. When do you want to do it? After every visit? Do you want to do it just after their initial consultation? Do you want to find out what they think after you've operated that on them six to eight weeks later? And how do you set these up so that they're part of your daily routine in your office? You could do it by QR codes. They create these. They're very easy and they click on them or they take a picture and it takes them somewhere. Those have become a little bit less in vogue but you can have them immediately receive a text or an email that requires them to give a rating and and give feedback. You can have tablets in your office and you hand them a tablet and ask them to fill out some feedback or you could just ask them in person yourself. In fact that's the most powerful way to get more direct feedback. Some people are afraid to hear what the patients have to say but actually more often than not you're going to learn things and you're going to learn things both that are negative and positive. So that is the best way to obtain sustaining innovations. What we all spend our time thinking about are efficiency innovations. These are the things I have to do. How do I make my schedule go well? How do I make the operating room go well? I trained with Bob Scholl and I remember walking out of the operating room once and I thought the surgery went great. Everything seemed to go smoothly in the sense that we didn't have any complications. There wasn't a lot of bleeding. The surgery seemed to be successful. What we tried to want to accomplish it was just a reconstructive procedure and we were out there in the hallway and he looked really upset. I'm like Dr. Scholl are you okay? He's like that was the worst surgeries I've ever been in. I couldn't believe he said that and when he I didn't know what to ask but I said what made it bad and his response was when I asked for this instrument it wasn't available. We had to wait for about five minutes for someone to go get it. I wanted this particular suture and it wasn't ready at the right time. When I reached back to grab this particular pack it wasn't available. I thought to myself wow I didn't notice that that was that bad. I've been a lot of cases where things weren't available but for him efficiency of time in the operating room mattered tremendously and he described it as being a director of an orchestra and you want things to move at the right moment so that when you need them they're there and if you have greater efficiency in the operating room there's less blood loss, less time spent that requires or that has a higher risk of deleterious outcomes. As I look at efficiency in a practice, this is how I broke it down in my mind over time. There's sort of three areas of practice management. You have the areas that bring money in which is billing and collections and you have all the things that require the payment of money so all the business management options, marketing, business development, spending time on cultural things to get employees to engage. Then there's which also has to do with your human resources and staffing and training and hiring, what business policies you put in place and then of course involved in that is scheduling because that drives how much money it costs to keep the lights on and all that you're doing in your office. What I think most people think about is the revenue generation. How can I make more money? How can we bring more money in? The truth is a dollar earned really only earns about 30 cents but when you save a dollar or you reduce what you pay out, you actually save that entire dollar so it's better if you're going to try to improve the bottom line from an economical standpoint, it's better to look for ways that you can improve the cost structure of your practice so that you can still accomplish the things you want to accomplish at the lowest cost. So efficiency innovations help you a little bit with that cost structure. So let's first talk about staffing. A lot of practices are afraid of adding ancillary secondary providers and these advanced practice providers actually can be a significant benefit to the practice because not only do they provide some immediate revenue generation but they also free up your time to do things that are even higher revenue generating. We should all work at our highest level of training. That concept needs to sink deep into your mind. You should spend the majority of your time doing things that no one else can do except for a fellowship trained female pelvic medicine reconstructive surgeon. Everything else ought to be considered as other work that someone else could be doing at their level of training. So if we can push things down out of our level or off of our work plate onto someone else whose training would allow them to do it, we should do that and we should train people to do that. So when you look at what you spend your time doing, what generates the highest revenue? Well the heavier things are surgery at the top, new patients that come through the door, and then counseling with patients whether it's regarding things that are not working well or are working well. The things that generate less revenue are non-surgical treatments, post-operative management, non-generating visit, as we mentioned revenue generating visits include not only post-operative visits and how many you want to have but you need to connect with patients. So this gets back to management versus leadership. If you want to maintain a reputation with patients, they feel like they had a relationship with their surgeon, you're going to want to meet with them other times even though it doesn't generate revenue. So the frequency with which you do that is critical for your practice success and for the health practice and for your reputation. It doesn't necessarily generate revenue so you have to decide how do I want to invest in this in a way that provides that high reputational experience but doesn't necessarily cost a lot of time and money. As you look at your practice you want to think of all the things that are lower revenue generating and push them on to someone who can still perform those services at their level of training. So that includes all the things that are listed on this slide but there are other things you may think about and you may consider. Three keys to having a successful practice with working with other providers is treating them as an equal partner and working together on management of the patients. Help them feel a part of this management as a team that they're not out on the island having to manage everything by themselves. So the key is you want to hire someone with talent, make sure that when you consider who you're hiring the most important thing you look at is do they meld with you in the type of practice you want to have. Do they share similar, are they like-minded and share similar ideas about how to treat patients and if that doesn't seem to fit then that's not who I'd hire even if they're very well qualified. Obviously their training and experience matters but how they fit with you is critical. You want to emphasize education throughout their career. You want to invest in them. The more that they feel like you care about what they how well they perform and what they know the more likely they're going to put more effort into the work that they do and treat patients better. Also you want to meet frequently and discuss these things. I think this is the most hilarious part about the business of medicine versus other businesses. It's almost as if we just assume every doctor out there, every practitioner out there will figure out things on their own and they'll just feel happy with what they if they just have a job but we all are trying to develop our own careers. We're trying to develop ourselves. It's one of the reasons we're motivated to go into this field and so if we do a good job of at least checking in and not checking in and say are you you know are you working hard enough but how do you feel? Do you feel like you're developing yourself in the way that you'd like to in the career that you're trying to obtain and are you happy with where you are? It's easy to ask the questions but be a good listener and have frequent visits and touch points is a critical item for success. There's a lot of questions I've been asked how do you support someone because they don't generate enough revenue with some of the things we listed to support the salaries that they demand. It's almost inevitable you're going to ask have to have a nurse practitioner or your advanced practice provider do some of the testing in your office because that revenue generation will supplant or support the other work that they do. At least that's been my experience and so some of the testing items we ask them to do are listed here. What I found because they're so good at what they do they're able to pick up nuances and make the test more effective particularly as it relates to aerodynamics but it's also true for endodontic ultrasound or it's true for anything. If you have a technician that does a very good job the information you gather is more accurate and it's more helpful. Let's move on to a couple of other things. I don't want to go into too much detail on financing but this slide is available for you if you'd like to read through it on ways that you can help them to achieve their revenue that they need to support themselves. This is a very generalized view of that but as it shows in here you're probably going to have to have them do testing because the feasibility of them just seeing patients that the revenue that that generates for just routine level three level four visits it would require more than 17 visits a day and that will burn out your nurse practitioner. So you've got to find other ways for them to generate revenue. How about physical therapists? What I've learned about physical therapy is it is critical to my practice. If I can't help patients solve some of their muscle dysfunction, I can't solve the rest of their problems, and they're very unhappy. This is by far and away one of the most important parts of my practice to generate the type of reputation, if you want to call it that, or the type of practice I want to provide, the type of service I want to provide. Turns out it's not a high revenue generating activity, but it will support itself if you're careful about how you set it up. It is critical. And then if you can help that physical therapist, just like the nurse practitioner, to love what they do, to develop a high level of interest and to work hard and empower them, they'll be a tremendous asset for you in helping your patients. Here's some of the numbers that you can look at to try to find ways to make it work. Their overhead expenses will be a little bit less, and it's all about how you attribute things. But in the end, they probably won't generate a tremendous amount of revenue for the practice outside of their cost, but they will at least break even. And my assessment of this is that it's always, my experience has been that they do provide some revenue, but the primary benefit is what they provide for patients. And it's just, it's invaluable. And I'm happy with the breakeven in this field. So, oops, I gotta go back one. Let's see if I can do that. I wanna talk now about things that I think are even more interesting. So if it relates to staffing, I think it's critical to create a team. And it helps you to then practice at the highest level of your training. But when it comes to your day-to-day, this is what every doctor gets frustrated with, is how do I see patients and how do I make it work more efficiently? You have the inflows that are constantly coming in, and that's critical. You've got to have constant new patients coming through the door. You gotta be good at being able to market and obtain those patients because they're constantly leaving the practice. The drain's on while the tub's filling up. So the things that funnel in are new patients. That drives your whole practice. That's the key indicator for how healthy your practice is, because that's what leads to all the other ancillary care and surgeries and everything else. Where you can find that number, if you wanna do analysis, is number of new patients and number of surgeries. Those two things, far more than anything else in your practice, will give you an indication of how healthy your practice is in being able to generate revenue. I'm sure many of you set up your schedule and maybe changed it a hundred times. I can tell you right now, this is a slide that I actually created about a year ago, and it's not even what I do now. I have a completely different schedule. I'm constantly trying to find efficiencies. So the way I do a new patient consultation, I'll have them in a room, dressed, talk with them. While they get undressed, I'll pop out. I may be able to see a post-op patient. So I'm actually, my schedule fills, has room for a lot more patients than this one shows. And then I'll go back into the room, do their exam. And while they're then getting dressed again and meeting me in my office, dressed and comfortable sitting in a new environment, I may be speaking with someone else. It gives them the time to look at things in my office that I have on display about a model of a pelvis or other things. And it lets them have time to kind of, I think, decompress after being examined. And then I'm seeing another patient during that time. And I've changed that. I've done a lot of different amalgams of this, trying to find efficiencies and using my time. So I'm, almost every minute of the day, it is me that is the bottleneck. It should not be patients getting dressed, undressed, getting back in the room, filling out paperwork. All those things happen so that the only thing that slows down my day is me. My goal is to increase both the number of new patients I see and surgeries. Five things I, this is from some research that's been done, but I also think that these are very helpful tidbits and ways to improve your patient flow. So when you get behind schedule, let your patients know. Patients will be very grateful and they're never upset if you just respect their time, like they're respecting yours. Just say, you know what? Something happened. I had a patient that was very difficult to work through the problems on, and now I'm behind by 30 minutes. If the patients know that, they can choose. Maybe I'll come back another day. Or this is, I'm willing to wait, and I'm okay with the understanding that it's gonna take more time. Allocate certain slots for procedures, follow-ups, new patients. I just talked about that. That will work as you bounce back and forth between patients. One thing that I have loved in the last year and a half is I hired scribes. I went down to Arizona State University, put up a quick advertisement for college students interested in pre-med or medicine, and I immediately got a ton of interested students. And it didn't take long to train them, and they're wonderful. They learn, they have good English skills, they're interested in medicine, and if I see one more patient a day just because I have a scribe, it pays for itself. And I don't spend all my day charting. It is a huge blessing, and I would encourage you to consider that. You wanna arrange your office flow in a way that reduces the amount of time spent walking from place to place, and you also wanna help arrange your equipment that way. You don't wanna have all of your aerodynamics, ultrasound equipment, everything in one room because then you can't schedule as efficiently. And then the key is to track it. If you don't track what you're doing, you'll never know how well it's working. And most EMRs have systems built in for that, then you can usually query that, but you want objective data. How much time they spend in the waiting room? How much time they spend once they're checked into a room? How much time did I spend with them? How much time did it take before they checked out? I mean, these are things that if you don't ever look at the objective data, you'd never really know. And then you can look for ways to find efficiencies. One way to do that well is to actually diagram it. Get a map of your office and draw a red arrow that shows what someone does if they come in for a cystoscopy this day. How far do they have to walk and what happens? How many places along the way do they have to bump through? You may wanna think about the time it takes to complete each of those things. And then look at variances between different types of patients so that you can schedule in a way that will be the most efficient. Most of you know this well. You learn this over time. So then you just gotta have a way of putting it in place. Another thing that I found that's very helpful is to do a pre-office day discussion for just a minute or two with your MA. If you've looked through your schedule and you know that Sally who's coming in at 11 o'clock is always super talkative or she's always gonna have a lot of concerns, or maybe you've got a patient that just has a slower ability to think through things and has a little bit of dementia, or if someone coming in who's deaf, you know that's gonna take more time. And if you talk it over with your MA at that moment and say, okay, I'm anticipating this, they'll help you. Say, okay, I need to get someone else back in between these and we're gonna lose 15 minutes here, but we're gonna gain it here. And just knowing that in advance really will help your staff help you to be more effective. Another thing I will tell my MA is if I'm stuck in a room and I'm the bottleneck, you help me out. Knock on the door, help me get out of the room. Help me see. Sometimes I lose track of time so that I stay on top of my flow. I mentioned this idea about planning ahead, but this engenders innovative thinking. It helps the MA think, how can I be a solution to today's potential problems rather than just having to kind of follow along? Eliminating factor, once again, I'm gonna say this over and over, for production in your office should be you and no one else. And if that's not the case, then look for ways that you can reduce those other bottlenecks. I think it's helpful when you say, if I do all these changes, how's it gonna help me? Financially, it makes a huge difference. I know it doesn't feel that way at first, but you'll see these changes. In our practice, this is data that's old, obviously, but after a couple of years and after bringing out another physician who joined me, she's fantastic, by the way, a very hard worker, but we found efficiencies. And now over time, if you look at here, this is just RVUs. A lot of you I know use RVU production as a way of determining how much work you produce. And these are the 13, 14,000 RVUs for each physician in the year. And then when you add all the other ancillary work that's being done for all those patients that we're seeing, it's a substantial amount. It attributes to almost 16 to 17,000 RVUs attributable to the work that we produced that year. And here's the thing, if it's efficient, and especially with a scribe, I can walk out of my office at five o'clock on most days and have everything done, including gone through my list of follow-up calls and things I have to do, and it's a great day and I feel good. So it's very possible. It's not that every day is gonna go that well, but there's a lot of things that I can do to make that happen. And if I do those things, boy, it makes me feel like I'm enjoying my job more. It looks like I've got about another five to 10 minutes to talk about disruptive innovations. I love disruptive innovations because it's what's changed our lives in business. An example of a disruptive innovation is the cell phone. Dell computers had to think about years back, we're really good at PCs. We can make them, we can produce them fast. We are good at how we create in our assembly line and processes, the various different types of PCs people may want in terms of memory and size and blah, blah, blah. But when people started coming out with these phones that connect to the internet, they thought, well, yeah, we'll start selling some of those. But disruptive innovations never are successful if you use the same management team to manage that as the new technology. So let's talk about what these new technologies are. What is a disruptive innovation? If you look at this graph, it kind of helps you to see that over time, innovation will lose some of its ability to evolve. So there's constant sustaining innovations, which in the business field, those things that they call them cash cows, they keep producing revenue. In our field, an example would be the mid-uterus sling. You don't have to keep innovating the mid-uterus sling. It's been productive, it's effective. And if you just keep selling them, because patients have these problems, you'll continue to produce a high probably margin on something that doesn't cost a lot to produce. And you haven't had to keep pushing that cost down because they're still producing a benefit that people wanna pay for. So that's a cash cow. And just sustaining innovations there is critical so you're competing in an elastic environment with the other producers on cost. So that is sustaining innovation. Keep making adjustments that will help you to compete on cost. But then something else comes along. Maybe it's a new way of fixing stress and cost. And you need to look at that with a different set of eyes and manage that differently. So what are the disruptive innovations in our practices? And here are a few that I've seen in the last few years. Telemedicine, which for all of us now we're familiar with because of this pandemic. That's something that I didn't even pay much attention to at first. I'm like, I can't do my job through telemedicine. But we were all forced to for a little while. And I can guarantee each of you had lots of new ideas pop in your head about, hmm, how could I use telemedicine? Are there certain types of visits I could do that in? And you had to do some of them. Then you probably thought, I could do this better. How can I change my schedule to allow for this? Now, because the government and now insurers are now paying a little bit more for the work that's required to do that, we're thinking, gosh, maybe I'll incorporate this in my practice. I can promise you that because of this pandemic, there's going to be a reimbursement system for telemedicine moving forward. Patients will prefer it. And so now it's a disruptive way of doing things. And you may have to change the way that you practice and think about it in a different way so that your schedule changes, the way you practice might change because of this. There's also a few others that I've seen. Direct-to-patient marketing, that was a huge change. The way we used to market practice when I started, I went out and met with every doctor in the community that would refer to me. That's how I thought I'd get new patients. But now it's about online reputation and social media. The other is concierge medicine. That's a big part of internal medicine and other practices. And certainly in a subspecialty, that seems like it couldn't work. But let's say that you're at the end of your career, how would you set up a concierge practice that allow you to do some of the things you wanna do without having to do everything else? I'm gonna talk a little bit about the direct-to-patient marketing because I think this is really fun to talk about. Then we'll end so I'll have some time for some questions. Interestingly, a lot of people think that all the online marketing we do doesn't fit for urogynecology. All of our patients are elderly. The majority of them in the ages of 50 to 70. So we're not gonna, this doesn't really matter. But one out of four minutes in the United States you spend online in almost all of our lives. And this includes older adults. 80% of adults have looked online for health information. This is old data too. This is from four years ago. I went to go look up any changes and it's just a small percent difference, but it's significant. So let's look at a couple of things. This graph is really interesting to me. This is the frequency that patients review sites, so going on websites. So some, a lot of them say, if you look at this, 50% of them more or less say that often or sometimes. So you're thinking, that's not very often. That's changed by the way, but now let's look at what they do on the site. So they'll look up websites before they see a physician, usually 75%, 72% of the time it says. But here's what I thought was interesting. Almost one in five go back and look at the site after the visit to either confirm, okay, this was the right person for me to see, or to say, yeah, I didn't know if it was the right person and now I'm looking at the site and learning more about it. Yeah, I think I would go and see someone else for a second. That's a substantial number. The sites that they go to aren't just your website. They're looking at sites that review you. These reviews are just done by anyone who wants to write on them. Can you believe that? But they, over time, there's been sort of a refinement of the ones that are most commonly used and here they are. And it's because they each offer something a little bit different. For instance, Raid MDs has the highest average of time spent looking at their site, almost three minutes. And that's sort of their special sauce. That's what they do well, that people spend more time on their site. The one that is seen the most is Healthgrades. WebMD has the most visitors overall looking at health information, but for doctors, not as many, so they're trying to link that in so that people spend time even looking at the doctors that are on their site. So they each try to create their own way to make their site important so people want to look things up so they can sell advertising. What I have found interesting is that Google and Yelp are now starting to skyrocket. So people now, more often than not, even in healthcare, are looking at Google's ratings on whether you're a good doctor more than even like Healthgrades or Vitals or some of these other sites. And so if you don't have a very good Google rating, that's a problem. How does that happen? Well, the problem with Google ratings is they're a little bit more stringent on who can leave information. And only one person can leave information one time because they can determine whether or not it's you or not because you have to sign in in order to leave information. Whereas these other sites, anyone wants to, can. In fact, you could go on there yourself probably and leave your own recommendation for yourself a number of times. They're getting a little better at that, but Google, that's their sort of core business is knowing who's looking at what and the information being accurate. So they are, they make it difficult for people to put false information on so people trust them more. So who manages all this for you? If you have a bad review on a website or someone else on Google has said some negative things, what are you going to do? So you need to think about this because it's a disruptive technology to your practice. We've learned that patients will trust whoever they confide in for that referral. And in my experience, it's less frequently a physician than it is someone else that they trust in their life. So if I look at my referral pattern, about 60% of the patients who come to see me are patients being sent by someone who only is referred to me one time in a year. And that usually indicates the patients come to me because of someone else who's talked to them and they tell their primary care doctor, will you give me the referral? I'd like to go see this doctor. And why is that? Because they trust someone else because we treat conditions that are very personal. So this is more significant in our field than any other, well, I shouldn't say any other, but the majority of others. So we really need to focus on what people think and where they get their referral from. So I ask the question, how did you find out about me? And almost all the time they'll say, oh, this doctor referred me. I'll say, then why was that referral made? Well, because the doctor told me to, or I told him at a friend who actually, they'll say things like, well, actually, at a friend who sent me to see you because they saw you a year ago. There's a lot of reasons, but if you don't start collecting that information, you'll never know where you need to spend your time. I submit that a lot more of your time ought to be spent on things that will draw patients directly and social media is one of those. People don't think that elderly patients spend time on social media, they're wrong. Pew Research Center tracks this, and it's really interesting. It's continued to rise. We're now up to close to 80% of people use social media in the United States. That's all adults. And this gives you kind of demographics by age. You say, oh yeah, we're only down to 30 to 40%. In 2019, that number for the population over age 65 jumped above 40%, almost 50%. It's growing. And what's interesting is where they're spending their time. This slide, I apologize, is old. I tried to bring the new data in, but I couldn't get it to transfer over in time. Facebook still is the number one by far, and this is at all age groups. You think, no, no, no, no, my kids don't spend their time on Facebook. It's true. Facebook still remains the top one across all ages. The second now is YouTube TV. So it even eclipses Instagram, Pinterest, LinkedIn, and Twitter. The third, which is a pretty significant jump down, but still maintains a strong position is Instagram. So if you wanted to spend time on any three things, those are the three I'd recommend. So the fun part is if you set up a plan about putting information out, putting out content through these media channels, you need to have a plan. Talk about things that are interesting. Create content that's creative, that's interesting. And you can even advertise with very little money so that you hit the population of patients that you want to have look at your data. If you do that, it makes your job more fun, I think. And working with innovation will allow you to grow your practice. And then you go home every day enjoying it more. One, because you found efficiency innovations, sustainable innovations. You empower your employees to help you produce these. And then when the disruptive thing comes along, you find a way to create management skills to help incorporate that into your practice. If you do all that, in my mind, it makes my job more fun. And maybe it's because I think these things are fun to do. I'd love to hear any of your thoughts and questions. And I don't know for sure if I'm going to be able to be accessible. I hope I am. And if not, let me give you my email address. We'll send it out. And you're welcome to send me any emails and questions that you may have. Thank you.

innovations

efficiency

enjoyment

patient feedback

staffing strategies

physician training

disruptive innovations

practice management