Private Equity Calls Her Every Day. She Still Won’t Sell | with Dr. Diane Madfes, BOAC #65

0:00So I started my own practice about 25 years ago because I wanted a little more flexibility as a mom with two young kids. And I said, oh, what's the best way is to do it? I should run my own practice. And I was a little naive because everything that had been taken care of for me in the systems with my old office and the hospitals all of a sudden dissolved. Boy, was I clueless. But it's better sometimes to be clueless because then you'd hit the ground running. but if patients can come after work you have to be there after work for them so in the beginning whatever the patients need and that's how you build a practice you build relationships you build taking care of your patients so that they know that they can trust you and that you're going to be there when they need you which means you're on call 24 7 and i think the hardest thing right now is everyone is so used to the non-human touch and a quick text quick whatever that to realize, no, you're going to have to speak to the people.

1:00I don't test on my patients. That's just not fair to them. I test on my family. Running a practice is also learning a business. They should be teaching better AI courses, actually, because time is the most valuable thing we have, and I think AI is giving us back our time. We're approached every day by private equity, but the way that I see it is I can do what they're doing.

1:32Before we get started, this episode of The Business of a Clinic is sponsored by Virillo. Virillo is the trusted marketplace for clinic owners looking to sell and groups and clinic buyers looking to acquire high-performing clinics. There are very few specialized marketplaces in the UK that focus on this transition for clinic operators. Virillo is one of them. Learn more at virillo.co.uk. Now on to the episode. I'm Sally here from Coherent Healthcare, the patient engagement platform. And we're here on Business of a Clinic with Dr. Diane Madfis. Very excited to be here in New York. I'm Dr. Diane Madfis.

2:10I've been a dermatologist for about 30 years. I have three offices and work with amazing fellow physicians. and I've seen dermatology evolve from simple medical complex medicines, diseases, to lasers, to aesthetics, to preventative care and excellent skin cancer treatments. It'd be great to hear a bit about how you started off in the clinic. I know we were just speaking about being in the first site and stuff and so would love to hear a bit about that. So I started my own practice about 25 years ago because I wanted a little more flexibility as a mom with two young kids. And I said, oh, what's the best way is to do it myself and run my own practice?

2:58And I was a little naive because everything that had been taken care of for me in the systems with my old office and the hospitals all of a sudden dissolved. So I had to, you don't have to reinvent the wheel and you follow really good models and mentors. and then I was able to start my practice. But boy, was I clueless, but it's better sometimes to be clueless because then you'd hit the ground running. So that's pretty funny to think of it being the easier way out to start your own business. And you were coming from working, you were saying, in the hospital systems? I was in the hospitals. I was in private practice.

3:33I worked for other people. One of the things when you have a medical office or a clinic is that the owner has a vision and you have to work under their vision. So you also have to respect how much work goes into building. So I learned a lot from the people that I had worked for and I saw what I liked and what I didn't like and how I thought I wanted to just make it a little friendlier. Again, I'm older and it's been over 25 years and medicine was very different back then. And your whole life was medicine and then you had your children. So now in my practice, which has expanded, we've expanded space, expanded other physicians, I try to be really flexible to my younger doctors so that they can have what I had wanted and had to start it myself.

4:23So the friendliness really around kind of maintaining staff or doctors or partners within the clinic. It's all of the above. You have to respect the people's time outside of the office. So it used to literally all be medicine, which it still is. And if that core goes soft, you're in trouble. That is your highest standard, is absolutely the best medical care you can give. And then making sure that the people around are happy when they go to work, that they're always being stimulated, whether it's your support staff who really make your life function or the other physicians that are in the office.

4:59So when you left kind of that being the actual doctor being employed by others and started off, was it just you in the clinic or what was the beginning? It was just me and an office manager and one medical assistant. And when you start, you are flexible. See, this is why I'm smiling now because I wanted the flexibility. But if patients can come after work, you have to be there after work for them. So in the beginning, whatever the patients need, and that's how you build a practice. You build relationships, you build taking care of your patients so that they know that they can trust you and that you're going to be there when they need you, which means you're on call 24 seven.

5:42So it's nice as practices have evolved. I got other help. I hired other physicians. And also now that we're able to have AI help us just a little bit also, because your practice can function 24-7, but you as the doctor, you really can't. It's interesting what you're saying. So I guess back in the day when you moved into your own space and clinic, how were you acquiring customers at that time and managing the relationships or building this up in that kind of, let's say, beginning of digital era? I guess it would be the early 2000s. It was really early. And what had happened at that time is it was just word of mouth.

6:23It was referring doctors that I had good relationships with. It was patients that knew and things start small and they don't have to explode over time. And it's just, you work hard to really give the best care. So everything always goes back to medical care. And medicine is exciting and explodes and changes all the time, but there's a lot to sort through. So you study, you learn, a patient has a concern, you have to dive into the research. Now it's easier because we have search engines and we have AI and we have open evidence. There's more data that you have to search through, but you still have to be really discerning.

7:09So in the beginning, it was libraries, journals, patients, and really reaching out to other physicians all over the country. So I think your network of who you work with, whether it's here or abroad or wherever you may be, super important. And so how do you think that kind of core of that service network and kind of human touch continues to today. You mentioned you're using AI. How do these things marry and work together? Or where do you think that the humans really involve versus the AI? How is the AI helping you? So we are old school in my office, because I feel you call the office, as long as it's during office hours, you should get a person.

7:53And that person is well versed in kind of everything that's going on in the office. They should know the scheduling. They should know the procedures. They should know the doctor's schedule. You call us, we should know your schedule so that we can kind of help. And yes, you can do it online. I'm available this afternoon or I can do this. But when you have a person and you can say, you know what, we have three offices. So we're in New York, Greenwich, and then there's a satellite in Florida. But we have patients from all over the world and all over the country. So you call and we know that you're going to be in New York, you're traveling through, the person knows what do you think you want to do?

8:33What's the downtime? Maybe we should hit you end of your trip. So without that person, I don't think you get as much of the care. So we're going to keep people. A hundred percent. It's really interesting you said that and you mentioned specifically around having that documentation around what you should do when someone calls, how you should approach it, what are the doctor's schedules, what information you have on your clinics and your patients and the availabilities and everything else, along with probably the really diligent training of years of knowing different procedures and what types of things happen.

9:11It's something we actually spend a lot of time with our customers speaking about and workshopping and onboarding on, which are working through the SOPs, right? Because you need that all really well documented, whether it be for another human coming in or any type of augmentation you would make to help enable that human. We really believe as well. We think that AI is fabulous. It's an amazing tool. It's not there to serve customers who are coming in for healthcare concerns, where they are very high value moments with human interactions required to actually take that. someone's coming in for their skin for whether that be an aesthetics treatment or more medical concern.

9:54You can't just have an AI. No, you can't. Suppose someone wakes up and they go, oh my God, I have a mole that's bleeding now. I like to have a person say, oh, okay, so that's on a punch list in my office. You need to come in and we'll get you in. And we have in the schedule, we build in emergency slots and all that. But it is hard, the onboarding, when you have a new person who's answering the phones because you really don't. I know everyone says a script, but I would rather them understand the workings of the office and the practice and the doctors. And also, so we have six physicians. Everyone can do most everything except some people are specialized.

10:35We have a pediatric dermatologist. We have more of a cancer person. We're all adverse in lasers. Everyone does medical because I think we're reversing sun damage and we're lasering and can't leave a cancer on someone or someone's been hiking and now they have poison ivy. So I really think you need to encompass the whole person. And I think that's why the office has been successful. And every time we expand something, there always is a little bit of a bump for information to trickle down. So for example, we're implementing new technologies all the time. There's different laser systems. The medical research is exploding.

11:14And I think actually one of the challenges that we have is, besides social media and the internet, is there'll be something that's been reported that's new that we may not be crazy about yet. And it takes a lot of time to say, no, because X, Y, Z. So for those things, we do have a script for saying, okay, what's new in the media? What's been reported on the news? And the nice part is my host staff kind of jumps in on that. They'll be like, I heard this. So then we come up with a script saying, we don't do this. We do X instead. Or we're watching it. Or check back with us in six months about this.

11:55But it takes a team to do that, not just a script. It's really interesting because you were saying that when you have a new person and you get them onboarded, and I assume Lynette and everyone else at the team, I've known since maybe I was, it feels like since I was five, practically. How do you actually go about documenting this information, making sure it's really understood, having people bringing a new patient coordinator along the journey of MADFIS as a clinic and what to do and how to act and how to answer the phone and all these things while, as you said, having them deeply understand the material is not just have it be a script.

12:33So we have three different forms of communication between the staff. We have our huddle, we have our WhatsApp, because we have a lot of people that work off site. So I'm very lucky that a lot of my staff has been with me for a very long time. And they really do shoulder the new people. But it's a good thing that we have staff coming and going because a lot of people go back to school. They get motivated and I think that's the best compliment. It's also, we get help from our patients. So our patients will also say, have you guys seen this? have you? And then it goes into the huddle. We use the huddle a lot.

13:08And so that's really around understanding what your perspective is on this new technology. What is the position of the clinic in terms of an external facing thing towards your patient saying, we either approve or don't or are looking into it, or this is why we think this other treatment's better. So we have a doctor huddle that's separate. And if there's anything new, I think the greatest success of the practice is that we stay on top of cutting-edge medicine and breakthroughs. So all of us go to conferences and we're always learning. So when a new technology comes in, it goes to the doctor huddle first.

13:42And then we look at the studies and we talk about what we think is good, what we should implement, what we shouldn't. Is there enough data behind this? And then after the doctors come up with the suggestions, then it goes down to everyone underneath. So that's kind of our filter system. It makes sense. And so what would you say is the makeup of the practice now? So you said six clinicians. Six physicians. Three are part-time, which is great because that way they have flexible schedules with their children. And we really try to help. But it's also the staff also needs it. And then we have a support staff of about 20.

14:19Wow. Yeah. You know why? Because we have people off-site. Right. So COVID stepped everyone up to being better remote. So we have people in remote areas, but it's all hooked up on, you hit the button and you're calling the office and then someone picks up. And then when I am in Florida, I have staff in Florida. So it's a lot of people, but then everyone can cover for other people and help train. And we're always looking to hire and we're always training because it really takes at least three months to train a new person. And what do you think are the kind of definitive things that make, let's say, front of house team member, whether that be on site or remote, really fabulous at the job?

15:05What are the characteristics you're looking for when you're hiring that? A nice person who's willing to learn. You can teach anybody, anything, if they're willing to learn and they actually hear you and they're nice and they get along with the staff. And if someone expects that it's just going to be A, B, C every day, it's not like that. Medicine is not like that. A practice is not like that. People are not like that. So that's probably, if someone's not flexible, it's not going to work. A hundred percent, especially with medicine and with such a high care practice, you have people really calling in and looking for that high care approach.

15:42It's not a copy paste situation. at all. And so that's amazing. So you went from yourself with one patient coordinator and a nurse to six clinicians, six physicians, 20 front of house staff. So that is almost... It's a lot of people. It's almost five per one, you know, six per one. Somewhere. I'm making a face. It's a lot of people. But everyone has different roles. But everyone's also cross-trained. And people go on vacation and people have lives. And it takes, as I said, it takes a good three months to train someone to know if it's a lot to invest in a person when you bring someone new on. Sometimes it works and sometimes it doesn't.

16:25And you hope that you learn quickly what doesn't. Every practice makes mistakes. And so we're like, okay, you're not a fit. And then, and I think the hardest thing right now is everyone is so used to the non-human touch and a quick text and a quick whatever that to realize, no, you're going to have to speak to the people. You're going to have to pick up that phone. You're going to have to call them. Yes, we have set reminders on appointments, on timing, on post-procedure and everything, but we, I like that phone call. Totally. Yeah. But younger people, sorry. It's a challenge actually. They're like, but I could text so much quicker.

17:11Yes, they can. They definitely can. We, what we found a lot actually is that when we're measuring the actual results of it, of calls versus WhatsApp versus SMS versus email, calls, they should be there. The number needs to be reachable for when the patient wants to call you. But especially if you are young, working, not in a good situation, and you just need to coordinate, going over WhatsApp as if you're texting a friend or going over SMS saying, oh, that's great. Or can I come in and see Dr. Madfus? I have a big bump on my lip or whatever it might be at that time is a lot more effective because you're just trying to get it done.

17:50But sometimes you just want to call someone. And so you should have both of these options open. We do both. And it's unbelievable the volume of the text and actually how much easier it's made. So if someone prefers that, it's great. But if someone's post-procedure or worried about them or we need to check in, they get that phone call. But it's what you said. You could be in a meeting and all of a sudden you just text them. Why? Now I have my 3 o 'clock appointment. And you've got to make it work always. So with 20 front-of-house staff organizing this all and, as you said, hundreds and hundreds of texts coming in throughout the day, emails, et cetera, how are they managing that?

18:25How are they going through that? It seems to be having to keep adding people to manage the… So we do a sorting system. And if someone wants appointments, it's very different than a medical problem. And I think on your end, you guys are going to have a little more of a challenge. Because if an AI program is reading and someone has a new bump or someone has a bleeding or someone thinks there's infection, that would send up a flag. So we've tried so many different things. And I'm still not happy. because you text and say, I'm healing from that infection I had three months ago. And now I just want to come in for my body check.

19:08It's going to be pulled up as infection. And then it's going to be like, oh my God, immediate. But it's not. So this is the challenge that we're having right now. So we have people sorting because my staff is very good and they're very quick and they can see appointment. And when messages come in, depending on, we know. So it's almost like we have a couple of people sorting and it goes, it's shifted. If you go back 10 years ago or now and someone, oh, if you want an appointment, hit one, if you want that. No, because that should be automated by texting. So we're working on it. Totally. We couldn't agree more at Coherent.

19:48So we actually think that AI has fabulous, as I said, we love it. I use it every day. I couldn't imagine my life now without it, to be honest, but it needs a human steer. And so anything that is outbound, we have it being done via AI and automatically. And we have codified SOPs and different ways to work that actually just surface the information for the human patient coordinator to be able to make the decision, triage it, say, oh, yeah, that was noise. This is not. Have a suggested response, prioritize rank and do it. But at the end of the day, it's the human responding. Because as you said, to get the nuanced classifier differentiation between had an infection that is now healing three months ago versus someone who is actively having an infection that you need to address.

20:35That is a big mistake, even on one patient. Which we can't afford. We can't afford it. No one can. But the problem is when you have volume. Totally. How do you fix that? And I think technology will save us. Totally. As it gets better. Oh, I learned. And it gets better. So you expanded from yourself. Can you talk a little bit of that journey too? Because it is Dr. Madfis Clinic. Now you have six clinicians and physicians. One, how do you find them? And two, how do you actually work on expanding it organically and naturally so that when I come in, I want to see you? But how does that work to start?

21:11There's only one of you. There's five, six other great... There's others. So actually, we changed the name of the practice. Let's go back. Okay, so we started and it was a small space, three rooms and just me. And then we grew. And how did I know that we needed to grow? Because you don't want to grow too quickly also because you don't want your overhead. You have to make sure your costs are good. But when patients in my office is on the corner of in New York, and when we had to tell patients, okay, go to the park, we'll call you when the room is ready because the waiting room is too small. That was when I knew we needed to expand.

21:49And then when you expand, you need more help. So then it took me a while to find someone. And I was lucky that when space opens up, so if you don't talk to people, so you need people, then you just don't know. So luckily the space adjacent to us opened up and then we acquired that and another doctor and two doctors. and my patients that I've been following for decades, I see them. So new patients that come in, depending on what they're coming in for, many times I will still see them. I'm limited. My old patients refer to me and I'll be like, okay, I'll see them. But then maybe they should be seen by one of the other doctors in the practice.

22:34So because we talk about tough cases and there's communication, there could always be better communication because everyone has lives. We try to funnel and say, you know what, this one's really better at this. This one is a better hair expert. You should go see this person in the practice. So it's not that everyone has a niche, but it does make it easier for patients. And we changed the name of the practice. So it used to be Diane C. Madfis MD. And now, and then we changed it to Madfis Aesthetics. And now we changed it again to Madfist Dermatology and Aesthetics Group because I wanted people to understand that you're getting a team of people.

23:15So we have no extenders in our office. We don't have PAs. We don't have nurse practitioners. It's just doctors. And that has been also the pillar that maintains our care as well. Not that the others aren't great and needed, but our focus is really on patients and their families and different issues that arise. It's interesting. So what made you change the name from Madfist to Madfist Aesthetics? Because I know you always were quite interested in both the, let's say, really strictly medical side of skin and then also the aesthetic side of skin. So it'd be great to hear that journey and what you've seen in the industry over time as well.

23:59I have always been aesthetic. So I've always been about 60-40 because I love the medicine and the medicine keeps changing and between the biologics and cancer treatments it's absolutely my and laser technology so for me I don't think of lasers as aesthetics I think of lasers as medical and the 60-40 has always been so the way that I like to approach it is there's a problem okay how can I best treat this problem and technology keeps catching up with us to help. Over the years, I've gone more 70-30. And now I'm at 80-20 because I have other physicians to help with the other problems that are going.

24:45And I've seen a lot of really good technology. And then I've seen some that luckily we haven't gone down that route. I think part of it is the training of the new technology and the aesthetics. And part of it is the expansion into Medi - into Medi - spas. And there's so many great practitioners out there, but when something gets blown up and then you lose your guidelines and then you have side effects and the internet talks about everything that's good and bad. So we're really particular. But the aesthetics has always been. It's just now we have different fillers. I only had collagen in the beginning, then hyaluronic acids.

25:23Now we of different biostimulators and we're going to go down a genetics pathway soon. So it's, and even with the new melanoma vaccine that, which came out of Moderna and COVID. So I am so lucky. And I think that's what keeps the practice growing is that medicine keeps growing, technology keeps growing, aesthetics keeps growing. So you have to keep evolving, but that's what makes it exciting for me and my patients and it's a team. It's a team with the patients too. and as my patients grow they also need different things so it's fun it's hard it's hard but it's fun totally and on that kind of and all the different things that you've been involved in I was wondering if you could speak to each of the brands that you've worked with on developing different cosmetics so what if you could remind me them so skin skin everywhere skin products everywhere.

26:19So I was very fortunate to work with the launch of Garnier Skincare from Europe to this country. So again, as the world has gotten smaller because of internet and knowledge and everything, a lot of products in Europe come here now, which is great. So many years ago, I was able to launch Garnier here, which started me on my path with L 'Oreal. So to be able to be the dermatologist to go into a drugstore and say, okay, I helped formulate this product that's now on the shelf, and it's good because of this, and it's helpful to patients. And it's, I think, contributed a lot to the practice. And then L 'Oreal has so many different divisions between SkinCeutical and La Roche-Posay and CeraVe, and then there's all the other niche boutique skincare brands.

27:14So So when you really learn, and that's another thing besides lasers, you learn to formulate and you learn what goes into products and you learn what to look for. Because again, you're counseling your patients because there's millions of things on the market and new things get changed all the time. So for example, someone could be using a serum that they love. Guess what? It was reformulated and now they're having an allergic reaction to it. But I've been using it for years. If you're not aware of the changes that are happening. So AI is going to help you because you can say, was this, let me see the ingredient list.

27:48Was this reformulated? And then you can figure out what's going on right now. And I look at niche and then I look at mass market. And I also look at a lot of products from Korea. It's really revolutionizing how small the world is becoming at the same time as skin types are changing. So it's, you really need to incorporate a lot into everything. And with that, how did you find the time? So you were running your clinic, you had your kids, which is why you started your clinic, is to make time for yourself. And yet you were taking on these other projects. At what point in your career did this kind of product form, being part of manufacturing, product formalization and such, did that kind of come into things?

28:30Ah, so I have a lot of patients. So if I'm giving a product to try, I have lots of family members that can try products and patients and so there's a new acne okay and I look at my daughter's friends and I'm like okay you guys try this tell me what you think so you can incorporate into your daily life and your family a lot of the things that you're doing when the kids were older and they're studying and the I would study too so you really because you want to be there so as they're doing physics I'm studying my cancer stuff. You don't sleep as much as you'd like to. And you can delegate. You have to have a good team to delegate.

29:16So say we know we want this particular laser, delegate out the contracts and things like that to other people. You have to have pillars who are around you. Otherwise you can't get everything done. I think when you're younger though, you don't need as much sleep and you get up early. and I also exercise. You have to have something for yourself. So I hike, I exercise and you can listen to things as you're moving. It's amazing. And it's so many different types of expansion. We were just speaking before we came in that you're actually breaking through the wall today. And I thought maybe you could speak a bit about how first the New York space has grown from you going from leasing it to acquiring different sites within the same amazing Fifth Avenue location and that journey along with kind of what happened to make the clinic within Greenwich and Florida and how those different sites operate.

30:13So it's not a one size fits all because your different communities need different things. And when you start bumping into your machines and the people don't have a place to sit, you know you need more space. and you knock on the doors of the people right next to you and you say, do you think you're going to retire soon? Tell me about the space. So we are in a vestibule that has three different offices. So right now we own two of them. And I knew because we kept bumping into things that we needed a little more space. So I actually looked at other space in Manhattan and to see what could accommodate for us and to make things better for the staff, for the patients, just a little easier experience so that they don't have to bump into, they're bumping into lasers and everything's used all day, every day.

31:09So we're moving things. It's a lot of activity, which is great. However, bumping into things. So when I couldn't find the space that I thought I wanted, I just knocked on the neighbor's door and I said, do you think you're going to retire anytime soon? And he actually hadn't thought about it. He was like, I was thinking in two, three years, I'm like, would you want to move up that timeline just a little bit? Because we need more space. And also I wanted to bring another physician into the office because of the other offices that we're in. So with COVID, a lot of people moved out of the city and the Greenwich office.

31:49I actually, I feel like there's always an event that triggers a movement or something. So I opened the Greenwich office after 9-11, which is here right now again. So people left the city. They just needed. And my patients were scared to come to New York. So I'm like, you know what? I live in Greenwich. This is silly. I should have an office for the people in Westchester and Greenwich. And that just evolved. So it's always a need that evolves. And now again, with COVID, a lot of people moved to suburbia, so we had to expand that office. So we switched from one office in Greenwich to a little bigger space where I lease.

32:31You always need to watch your overhead and your expenses and your staffing and everything, but you also need to be available. So if there's certain things that need to be done, patients have to come to New York. So it's a full office in Greenwich, but it's only limited hours. And New York is so nice. Snowbirds. A lot of my patients go to Florida during the winter. It's cold. I don't blame them. And they were coming back after their time there. And I was like, oh, what happened here? So between the aesthetics and cancers that were growing, I was just like, okay, this is not good continuity. of care.

33:13So for better patient care, we opened a satellite. So I was referring them to friends who are in Florida because you ask us and you need help. We can't be everywhere. So when they were having trouble getting into the people down there, I'm just like, and they're like, Diane, just come here. So that satellite popped up. Do I need another? Everyone's joking. They're like, oh, we need a satellite in London now. I'm like, no, we're pretty good for now. I have colleagues all over, wonderful people that I collaborate with. And the nice part is that there are other physicians in the office that can also move to the other offices as they age, as their careers change.

33:58It's other opportunities for the other physicians as well. It's amazing. So you run Greenwich and the satellite in Florida very differently than New York. And what do you... No, Greenwich, not really. Greenwich. So Greenwich, you said, is it still limited hours or what are the doctor... What's the setups? You have the six... The setup is we're there once a week. And right now, me and one other physician are there. But if any... But thank you, AI. Thank you, technology. technology, everything flows to New York. Everything's handled in New York, which is great because you don't want double staff.

34:37You don't want double staff. So when I'm in Connecticut, New York staff goes there. And then when in Florida, I do have separate Florida staff. So that works out a little differently. But Greenwich, so you always look to the future. You look for, okay, where should we expand and where should we not expand? And Greenwich, and you'd look at, okay, so it's also a business. We look at housing markets. When we see housing markets changing and we know Westchester's up, Greenwich is up, other areas in Connecticut, you know that's an expansion market. So moving forward, the Greenwich office will be expanding.

35:17And would you expand it? So right now you use it, it's open one day a week. How does that - Although every other week it's two days, but - Would the expansion be that you are open more days? Would it be that a clinician is based there? And also, how does the, you were saying about keeping overheads low. Is it that you're renting out the office to other people for other days? We lease in Connecticut. It's a gorgeous space. We lease because we don't need to own. New York is the base and all the EMR, everything was in the cloud. So it's fabulous. And will there be a time when we'll have to acquire space in Greenwich?

35:53That would be a lovely thing if we needed to do that. But you always have to, I'm sorry, medicine is amazing, but if your business is not successful, you can't continue it. So I'm always looking at real estate. Should we be acquiring space in Greenwich? And right now the answer is no, because our space is amazing. And my landlord is amazing and has space for us to expand. So that's another thing is that I would always recommend that when people are looking at spaces or clinics, you're not looking for now. You're looking five years from now. Makes a lot of sense. And so the other four days a week when it's not open, is that space being utilized by anyone else?

36:38Are you subletting it? We sublet it. And so that's another thing. What in the space that you're subletting, who else is in that space when you're not there? and is the general feel of the office a good one, even though you're just leasing and you're just not there because you're really looking at the entire brand of a practice. And when we're not there, the other doctors and the other practitioners in that space in Greenwich, they're A1. They're great. That's fabulous. So when you're looking for a new space or looking for that time, you're looking for the future, but you're also looking who else, who are you sharing it with?

37:15Who are your roommates? Are they tidy? Are they having the same level of care as you? Always, which is probably a little excessive because obviously it's a different type of medicine. It's a different practice. But I think patients should feel confident when they walk into an office that they're going to get really good care. And if they're walking in an office that you're leasing from someone else, you should make sure that office is giving amazing care, which we have in Greenwich. So I'm very lucky, really lucky. And with Florida, when you're trying to go between in the winter, how do you maintain being in Florida for your patients, but still present in New York for your patients or kind of sorting that out?

37:57Other people in New York. And that was one of the also the impetuses to expand the New York is so that when I'm not there, I know that the patients are taken care of. I go to a lot of conferences and I lecture. I was just in Barcelona lecturing. So I try to piggyback the Florida with when I'm going to be out of the office anyway. So maybe I'll cut down on a day of a conference or a travel day will turn into a patient Florida day. So you always have to work on the schedule and communication with the patients, which is through our Instagram, through our texting, through our emails, letting them know when we're going to be where.

38:39It's probably one of the biggest challenges right now because they'll be like, oh, we didn't know. And it's what you said, a way of reaching out. So we actually stored the patients by Florida patients and they get all the alerts. Okay. These are the dates that are coming up now, are we losing catchment because, say, your friend is in Florida and they're a New York patient? And the answer is no, because we're also working on that in terms of better communication for all of our patients. So how are you actually approaching communication like that? What's the roadmap or how are you looking at assessing it and understanding, let's say how effective it is.

39:26So we can tell by actually phone calls and texts that come in. So in response to what we send out and our alert, we will get the numbers back in terms of people making appointments, people responding to the texts. And it was really good about three years ago. And I think everyone is getting text fatigue. And a lot of people don't want spam. So the spammers are killing not our business, but everybody in terms of it's harder for a patient to sort through what's real and what's not real. So we try to give people a heads up. And we just added, which we'll see if it works. I don't know, on their text saying, please go to your email.

40:20And we're trying to highlight something specific in that. So something that would relate to the patient that they would understand in the email. So it's a little, oh, why is Dr. Madfus emailing me? And then it'll get that information there. Now a quick break to tell you a little bit about Coherent Healthcare, the company behind the business of a clinic. Coherent helps fast-growing healthcare providers engage, support, retain, and nurture their patients from intake to discharge. As you get bigger, your patient body grows enormously. And it becomes much more than just another hire, just another front office team member.

40:58It's no longer a people problem. You need technology that can scale with you. Coherent helps you do that by keeping every patient on track. In short, we're the agentic CRM and patient support platform for outpatient hands-on healthcare. To learn more, visit us at coherenhq.com. Now back to the episode. Interesting. So you want to have that more personal engagement, which completely we could not, again, could not agree more. It's really what it's about is making that personal connection as if creating that entire unified experience where it is really in the benefit of the patient. Hey, we are here in Florida at this time.

41:34Make sure you book or we should probably have this checkup because it's been a year and you're of officer in age or at risk of skin cancer. I know that you even always told me to check my mors. Yes. And it's also good sun education. And it's also good preventative care. So there's so many different benefits to people knowing their skin. 100%. And so that kind of level of care, I think that there's fatigue. But you want your practitioners to be caring about you. You want the clinic to care about you and to nurture that relationship over time. I know you mentioned that. Yeah, but how many times do you get a text?

42:10Oh, thank you for coming. please rate us. Oh, thank you for coming. Don't forget that. I mean, it's just like it's overload on people, everybody. A hundred percent, because at the end of the day, you're asking then instead of you delivering the care to the patient, which is checking on them, making sure they're okay, you're actually asking the patient to deliver a service for you. Rate us, which is very important. Thank you for coming in. Okay, that's really nice. And we're so grateful to the patients. I don't need to send them a text to thank them. A hundred percent. Really one less communication going back and forth.

42:40And I think it's just overkill right now with too many clinics and things. Too much information, too much, and not high value, like low value messaging noise. That's a good way to think about it. High value contact. A hundred percent. And if you could speak a little bit more about the plans, you know, you were saying, you know, it's time to expand when you're getting more people in and doing these things and you're trying to expand. How do you understand when you need to hire someone new to come help you manage that kind of new influx of staff? Again, you have a very high staff ratio. We do. We have very high staff ratio.

43:16And some people say it's too high, but I don't think so because a lot of younger people are moving or they're getting married or they're having children or they're going back to school. Going back to school. Education is huge for me. How do we manage it, though, with such a high staff? and how do I know when it's time to hire? We know around vacation times actually. So if we're having difficulty coverage because people are on vacation, that's a no to me. It's time. In terms of patience, if people are having trouble getting in, and that's really easy, just look at your appointment book. 30 seconds.

43:58And then you know, okay, it's time. I also asked my staff who's answering the phone. What are you guys hearing? Are you finding out that there's a particular day that we're having a problem with? So if you don't ask the people who are answering the phone, you're not going to know. And it doesn't matter if it's one office, two office, or three office, It's the same phone call coming in. So what we've been thinking about is should we have a checklist? I personally check in with everybody on Fridays and say, okay, so what calls did you get this week? What are we not addressing? What should we be addressing?

44:35But I'm just one person. You really need your office manager to do it or your head of your medical staff to do it. And that can be in any clinic. Just saying, okay, everyone wants to come in on Thursday afternoons. Guess what? We need to add another practitioner Thursday afternoons. So we've tried also sending texts out to the patients saying, what would you like from us? Would you, is there a day where you need more office hours? One of the problems is we got, oh, we'd love a late night. And, but that's really hard on my staff. It's really hard on my staff because they have lives and they have families that they need to get to.

45:16So we'll be like, okay, we're thinking about it. But if you have staff that's unhappy, you're going to burn them out. And so now if we got a thousand requests for a late night, we would add a late night. So you always wait. There is benefits. It's funny you're speaking about this because I was literally just building it this morning before coming. We're working on part of having automated outreach going out and human coming in. And the good part of AI, which I think we've talked about in other moments a little bit before, is what the technology can enable. And so in having all of the messages inbound be completely in one place, sortable, organizable, and having all the call transcripts and everything else, we are having AI surface those patterns and recognitions.

46:05What are the standout information that's happening today? five people, I won't mention the clinic, but we just reported to someone that, you know, five people in a course of two weeks complained that the clinic actually canceled on them and then was unable to find them, didn't rebook them, didn't message them or anything and didn't try and reschedule. And so it's wonderful for that clinic to have the catchment. To fix that. Or to say, as you said, oh, wow, this is a real standout thing. We keep hearing this theme. People want, everyone was trying to book for a Thursday and then they said, oh, actually, I was trying to book, I was trying to book with this doctor, but I couldn't come in.

46:41They didn't have an appointment for weeks. And so I went somewhere else or information like that, of how could how can you then start solving it? So having that oversight and view in and visibility to be able to make the clinic experience better is something that we're actively working on. What's the sentiment? Are people positive or negative? Sometimes we get ones which we would never surface, especially in the UK, where people are a lot more reserved than, let's say, in New York, especially a lot more reserved. But sometimes we'll get more unpleasant messages that say, I actually was never going to message you and was considering suing, because I had 100 % the wrong clinical diagnosis and information and continue to work out on a leg that actually caused me further damage and injury for a year or this MSK clinic or a aesthetics clinic again with lasers.

47:35I came in for this and I ended up with scars and I was going to write about, I was going to write to you, but then no one followed up. And so it's upsetting. But at the same time as a clinic owner, surely you would want to know how the staff is, how people are reporting, what's handling, how can you make it a better experience for them? Or I've been waiting for my x-rays for three weeks now. I keep emailing in. No one sent it. And so surfacing these results, as you said, is very valuable. It's very valuable. It's really, because one person can't do it all. So you really want to make sure you have systems set up in your office to try and handle it.

48:14And luckily, technology makes it so much easier now. So much. But I worry. I worry about the cracks. I really worry about the cracks on things because no one should fall through a crack. But most offices are automated, though, in terms of results, making sure things are notified, flagging on systems. You have to combine the human with the technology because you're not doing the best service to your patient if you're not. We call it the leaky bucket syndrome. Yeah. Because their patients leak out all over. They leak out when their new leads coming in. Because someone, you follow up once, maybe twice, or someone takes 24 hours to get back to them and they go somewhere else.

49:04It's now with DERM and medical aesthetics, it's become such a, as you said, for kind of the worst of it too, such a competition out there with Instagram, with people always posting with all of this information. It's hard. It's really hard. That's why we've always maintained the base of the medical, because in the end, we're doctors who are trying to make the people look better, age better, but also be able to help them with things that arise. So there is right now, there's the huge insurgence of women's health. So I also belong to something called WAM. It's Women's Health Access Matters. and it is a group of people and it's to give awareness of women's health and medical care and we target different things in terms of cancer, autoimmune, dementia, Alzheimer's to make sure that research is actually going into these areas that really haven't for women.

50:06So that's a passion for me and I see the leakiness happen in women's health right now. So that's why the medical is so strong for us also, because as we're shifting and I'm also, which you probably don't know, I'm also menopause certified because a lot of my patients are women. And I feel that particular knowledge base needs to be there as my patients are getting older. So then I'm able to help them again with that transition as well. It's amazing to hear that you're working on that. I think about it a lot. And I say it, I feel like once a week, I think to myself or say it out loud. oh, I really hope AI is, someone's using AI to try and solve the women's health issues, especially hormonal, every single type of problem.

50:52I feel like this is such an unpop, for some reason, even though we're 50 % of the population, if not more, and have way more sentiments, feelings, you know, akinments, we're ignored fully. And I'm just thinking. We always ask our patients, what's going on with your hormones? What's going on with your symptoms? And really trying to get an awareness. and then we have a great network that we work with that are able to help. But I was lucky that I was able to help with a bipartisan bill to make sure that if a drug is taken by a woman and it's funded by the NIH, women have to be included in the study.

51:26So it sounds so simple, and this was never a thing, and now it's a thing. So I was lucky enough to be able to work with this fabulous group of women, not women, it's women and men, to really get this change in Washington. So I am very busy. I am very busy. And I can imagine now with the kids out of house, it's even more, it didn't slow down. No, it just shifted a little bit, which is good. But again, I never lose the focus of the practice, which is really good, solid medical care using technology to help us take great care of our patients. It's interesting with the female health, let's say, train of thought, because it does sound like you would now that I'm saying it, but most people wouldn't think that a dermatologist would need to have that secondary background.

52:17But are you finding it to be a bigger trend overall, looking at the body more holistically or understanding what's happening, whether that be saying, OK, women's health applied to dermatology or other. You mentioned autoimmune diseases or different versions. We see all the changes. And that's why derma is so amazing is because we actually get to see their hair is thinning, their skin is dry, the pigment's changing. There's a little more wrinkles. There's a little more hollowness under the eyes. The areas where we see the aging, we know it's as hormones are coming down. And the fact that it has been ignored, and it has, but now it's not.

52:57Everyone's awareness, and we've been talking about it. But we've been in dermatology, been trying to help the people for so long. And now, see, this is the part that I'm happy about, is that because everyone else is aware now, it's making life easier for us because the conversation's already been started. and the funding for health research is coming. And it's something you can talk about now. So we've been using lasers to stimulate collagen and fibroblasts and topicals. And the whole body, as we've spoken about and you've alluded to, it's not just skin. It's not just your hormones, but it's the food you're taking.

53:35And it's everything. People are more aware, and so they're actually raising it to you. Is that something that you're seeing as a patient trend? So it's patient awareness for women's health that's actually continuing the drive. And it's also the most amazing part of social media because it's not only the gynecologist, it's the urologist, it's the oncologist, it's the primary care practitioners, it's the rheumatologist, it's the endocrinologist. So what people forget about women's health is that as a woman ages, all the parts are starting to, I hate to say it, but break down. There's a lifetime on things and you really need to have everyone work together.

54:16I think in five years, though, it'll be normal for the practitioner to make sure, okay, we're addressing the heart, we're addressing the bones. We always address the hair and the skin because it does changes. And the patient awareness as they come in, knowing that there are things that they can do to make it better and be healthier. We're also a lot more active now than we were 15 years ago, but there's a subset. So I think you're lucky because it'll be figured out. You get there. The problem is you do not have data to support a lot of what's going on. And that is the hardest part that we're finding in our practice.

54:57People will come in with a list of 20 different hair things they should be taking. And we're like, okay, the data only shows the top five. And they're like, yeah, but I saw this. And I'm like, that's good. it may be better later. So the communication is going to have to be better between all the specialties. And I think that's going to be the hardest part. But everyone always laughs at me because I say, that's where the robot's going to come in, because the robot will dump all the data in and then it'll kick out, okay, these are a couple of algorithms that you should be following. And then the doctor will help and navigate what else is going on.

55:36It's interesting. So what has been the change you've seen in practice of, I think, again, New York especially is a very self-advocating, knows what they want type of city. But in general, what has been the trend with social media, with everything, with the aesthetics? I think we talked a little bit about it of even for something like polynucleotides or being someone who's young like me being like, oh, I think I'm thinking I'm getting this because I see my friends doing it. I see it everywhere. And you said, maybe not. It's just that there's so much out there and it's amazing. A lot of it has solid science behind it.

56:08But I think what we're learning more about epigenetics and cellular senescence is that there's only so much of a life cycle a cell has. And if you start stressing it or traumatizing it too early, it's not going to last you long enough. So why should you attack things that shouldn't be attacked at a younger age just because people are aware of it? So that is probably our biggest little bit of a pushback that we get from patients because yes, we offer the latest and the greatest, but a lot of people are a little too early for it. And I don't think they should be going down that road. Plus you don't know in three years from now, if maybe it sets you on a different path that you shouldn't be on at this point.

56:55So a lot of the exosomes and proteins and messenger RNA products are reprogramming our DNA. And are we going to see increased skin cancer? Because now the cells are replicating. There was a time when people saw changes with growth hormone. And then people backed off on growth hormones because they were concerned about other cells that might be growing. So are we going to be seeing that? And only time will tell. So if there's a problem, treat the problem. If you can prevent damage, prevent the damage. But if you don't, the question is how young is too young? When we see now a young person, let's talk about sun damage or wrinkles or aging, photo aging, okay?

57:41Someone who grew up in California is very different from someone who grew up in Alaska or someone who grew up in Connecticut or Florida or Texas. That's when the human comes in. You could write an algorithm, though, that says, where are you from? And then how long did you live in a particular area? And how much sun damage did you get? And what are you doing for this? So there's going to be amazing ways to sort out what should be done, what can be done, and what will be done. And how do you deal with that from a clinical experience situation when a patient's advocating for something that you respectfully disagree that they should get?

58:17Like, how have you seen that change and handled that in clinic and as a shift to navigate those challenging? I always say that's why there are multiple physicians and multiple brains and people see things different ways. And I say, you know what, let's get a second opinion from one of the other doctors here because maybe they know something that I don't. And most people are open to that because you get a second opinion like right then and there. That's one of the great parts about the practice is that you have that access to all the other doctors. Are they going to leave and go somewhere else?

58:53They might, but we're there if they want to come back. And I'd say most of the time they do. Not that anything bad happened, but just they didn't see as much of an oomph because they didn't need the oomph. We're, I'm very lucky because we take care of families and we take care of people when they're young. then they get married, they have babies, we take care of the weddings, we take care of when they're older, people retire. There's so many different levels of taking care of patients that were there and if for a particular time in someone's life they need to go to a medical clinic at 3 a.m in the morning because that's the only time they're free because they're working on a startup, you have to respect that.

59:35So work around that. The importance to me is that you never lose sight of the patient. And I think in the grand scheme of things that some of that's starting to happen. And every patient's different. And even though you have your algorithms and you have your scripts that you're working to make sure that your staff and your patients and everything is set, you have to remember that everyone's an individual. And I don't want that to be lost in medicine. And that's, I think, the key to maintaining good relationships and trust over time. How do you actually do that right now in terms of using your patient management software and in terms of having it?

1:00:16I know you've known me since I was five. You've known my parents even longer. I think I could come in, you would remember every single problem I've ever had. But that's not as expansive as especially if someone needs to go and see. If I have to come in and you're like, actually, I need you to see my colleagues, I'm not in. How do you actually maintain that level of detail information? And so we, the vetting process of my colleagues is pretty intense, actually, to make sure that they have some, they don't have to, so everyone practices medicine differently. And that is one of the best parts actually about the office is that there's no cookie cutter way to treat because everybody's different and you get a perspective of that doctor, but the general values and how you take care of the patients are very much the same.

1:01:07And they'll be like, oh, I saw Sally because you weren't here. You were at a conference and this is what happened. Or I'll see a pop-up in my box saying, I saw Sally and she's being followed for this and we're so happy that this is resolved or what changes. So we actually use the communication to help have better coordinated care between the physicians. Again, it's a trust thing, but just takes time and manages. Also, we know as you age what you're going to need. So we're watching out for that at the same time. There are a lot of skin diseases that have long-term complications. So we're watching that for Women's Health.

1:01:56We're watching that also. I'm like, okay, did you get your estrogen supplementation? Can you do that? And did you speak to the bone doctor yet? And what's going on with your cholesterol med? Because it's causing this problem in your skin. So, you know, we're always building on top of. It's never starting over. It's always building on top. And I think that's the benefit that happens when you're with physicians for a long time that I just don't want people to lose. When hiring each of the additional physicians that you have, what was that process like? Like, how did you find the people you really trusted that had the same values?

1:02:34How have you built in that core identity and understanding of how to handle patients or how to do this? It has to do with a passion for medicine and for learning and discovery and hearing something new. and how did they evaluate that new idea or that new tropic or that new drug? And one of our physicians, she teaches at a medical school in residency programs. So she's involved in drugs development and then another person. So you're always looking for a particular strength to add to the other doctors that are there, which is why if someone had a hair problem, you'd be like, yeah I'm going to the hair person in Madfis's office because that person's gonna be really great.

1:03:21Every and we encourage I do a lot of laser work a lot I do a lot of scar work actually and we also do a lot and then we have someone who does a lot of acne so the piggybacking of okay let's get their acne under control and then we'll work on their scars after so it really is a community taking care of the patients. It's hard to vet but you really want to you want to hear it in their voice. You want to see it when they take care of patients and what they're learning and what journals they're reading and studies they're looking at. So it's great to have the brain keep getting bigger. And how often do you, because I know you were very early with lasers and working through them.

1:04:04How often do you upgrade the machinery or change it out or try a new laser? And what is that process like to understand whether it's time? What are the pushes and pulls to understand and then to test it out in a clinical capacity, but on your own patients? How does that work? I don't test on my patients. That's just not fair to them. I test on my family, and that's okay, but not on my patients. If there's a need that I think a patient and we're not addressing it properly or good enough, or maybe we can do it better. For example, CO2 resurfacing that's been around for 25 years we've been resurfacing people I would love people to heal faster so how do we get them to heal faster do we look at new technology what changes are happening so the process of resurfacing but then the new technology that emerges and then when you ever you look at a new technology you have to look what happens three years out after you've used it.

1:05:03So three years is early. You should be looking at five. Okay. But then you also have to look at the people in the studies, what age are they at? Are they at a, oh, are there a lot of women going through menopause and now their skin is not going to age as well. And so you really need to tear apart these. And that's what colleagues are across the country. That's what your studies are. So when you hear about new technologies, I have so many roundtables that I speak with other physicians about I and what we want. The companies are also great if you say I need someone to heal faster. They don't have 10 days.

1:05:36They only have seven days which may not seem like a lot to you but it does if you're working or you're traveling or you have your children you have to take care of. So luckily the companies are helping us with our needs but you just don't bring something in without looking at the research behind it. So COVID slowed everything down because you really do need those years of follow-up and with the company's studies. Whenever you do a laser or a treatment, you have a baseline, then you have follow-up, then you have three months, then you have six months, then you have a year. And if people can't get into office because of COVID, you're really behind on your studies.

1:06:15So now everybody's catching up and you'll see more of an explosion of technology. Plus, we have so much coming from Korea all the time. And so we may have radiofrequency microneedling, but now we have, I'm like, you know what, I'd like it a little faster. I like people to hear a little. So let me see what new technologies are coming here and how we can just, I don't think of it as an upgrade. I think of it as better improvement. It's not an upgrade because the old was really good, but now we can do even better. This is a different way to think about it. Sad Jared isn't here. Maybe you have to end up speaking to him.

1:06:53His background was actually in laser development and running an aesthetics clinic and trying to go through that entire life cycle, what it takes to go from a Princeton lab, essentially, to actually being in market and what those tests are and everything. So it would be an interesting conversation within that. It's hard. People don't realize it's not, you don't just aim a beam and you find because you need your biopsies. And now, So on your samples, you can just run biomarkers on everything and it can be analyzed so quickly. So we're getting results faster in terms of, oh, maybe we should be targeting this instead.

1:07:34And then let's look at different recipes of different technologies. And if we have three of these, how can we pick up other five and maybe we can add something else? So I think of it as cooking. So now we have different recipes that we're working. but you have to be careful you always have to be careful because you don't want to shut down things at the same time when you really want to boost them up and then what are you boosting so again i feel like i'm adding in my head up all the different things you're doing it's kind of fun how much time do you spend as part of helping clinical research and development of new technologies or and then let's block that off then have of skincare products and skin lines and then of building the practice and maintaining it and then being a practitioner and then everything else, which I guess you just don't sleep, but.

1:08:24Don't sleep, but I exercise. You got to exercise. You got to move. You got to cook also. So you have nice, healthy food. Every day I read for an hour, whatever the new journals are, whatever's coming up every single day. And then about every six weeks I'm at a conference. And so when I'm at a conference and I'm doing, seeing the new technology or new skin creams, I can piggyback that at the same time. So I'm pretty efficient with my time. And then the practice, I live the practice and I live my patients. So it all works. For people starting out, how would you recommend them building up their networks and getting out there and spending time?

1:09:01Because it seems like it's so important to have a deep network of other physicians and people you respect, as you said, mentors who got you started and stuff. How do you actually build that up to stay really involved in the community, which it seems like you think is very important to achieving great results? I don't think you need to stay in your lane. You really need to reach out, especially with women's health now. You need to reach out to your gynecologist, your internist. And I think the other specialists need to communicate better. And that's why there are multi-specialty practices. But everybody's so busy, they don't talk about the medicines.

1:09:39So when we have, if you're starting out, make sure you have a good gynecologist and OB that you can talk to. Make sure you have a good ophthalmologist that you can pick up the phone. And all it is just saying, hi, I'm a dermatologist and I see a lot of patients with ocular rosacea. And how do you treat that? And then do your due diligence to find out from your other physicians. and then you can send them so that your patients are happy that they're getting good care. And then they'll be like, oh, she couldn't do that, but she sent me to someone who could. And so I think it's really important to look at your resources of what you're doing.

1:10:22And always be humble, actually, because there's so much we don't know. And you should learn every single day. You should learn something new. And young, and when you're in your training, you really do need to step outside the box of what you're just being taught. Running a practice is also learning a business. And now in schools, they're teaching business courses as well, but I think they should be teaching better AI courses actually, because I think it's gonna, time is the most valuable thing we have. And I think AI is giving us back our time. So I think, oh my gosh, can you imagine in five years I'm going to do even more because I'll have so much more to do and work and help take care.

1:11:09Do you have a lot of relationships with, let's say, younger doctors who are just starting off in their career who are looking to you as a mentor, who are working through things? And how do you balance that or choose to spend your time, your very precious time engaging with them versus not? you mean like tomorrow morning when i teach once a month at mount sinai medical school so i get to work with the young doctors and teach our residents yes i do that once a month in the morning on fridays so that i do keep that connection because you learn from them also what new studies so mount sinai which is where i'm on staff we have so many clinical studies And every week we get an email, okay, these are the things.

1:11:56And then we have grand rounds. So this morning, before we met, we had a fabulous hair loss lecture and the new drugs that they're working on over at Mount Sinai in the research. And also a couple new drugs that are in the pipeline. So I do get to work with young people all the time. And the hard part is when they come and we do have some people come into the practice. but I have such patient privacy that I really feel the focus should be on the patient, which is why I'd rather go to the hospital and teach in the clinic there so that the people have my undivided attention. It's just better. You have to draw some boundaries.

1:12:37For sure. And do people ask you a lot about running the practice, or is it really around medical? Like how many people are thinking about setting something up themselves versus being employed versus just wanting to be interested in it for the medicine? Like how many are business-minded would you say? If someone's business-minded and more of an entrepreneur, they're actually going to look outside of running a practice these days because private equity and different businesses are acquiring, hospitals are acquiring. So I think people are looking beyond. There's still a solid business base that you can learn from running a practice.

1:13:14but it's more like a physician comes in they're gonna do their thing and they're gonna go back to their family or you've had this very successful practice have you been approached by private equity groups or thought about selling or what happens after yeah we we have we're approached every day by private equity. But the way that I see it is I can do what they're doing and I don't need to go there. And again, you have to, as long as you can maintain great medical care, keep up with technology, study, have good communication, you don't need private equity to do what you can do. Makes a lot of sense.

1:14:06Thank you so much for joining us. I really appreciate it. Is there anything else you think we should cover? We have the benefits of technology, benefits of communication, benefits of medical research. There's going to be better sourcing. There's going to be better communication in the world with education. I think it's a very exciting time for medicine and for different medical clinics. And I think you had mentioned something about competition. I don't think we should be thinking about it as competition. We should be thinking about it as a collaborative effort of everyone working together to just provide better care.

1:14:51Also, our health care costs are through the roof. And I think as technology and the robots start helping us narrow things down, I think better preventative care will actually be helpful for everybody. And then we'll have more data, especially for women's health. Thank you so much. You're welcome. Thank you so much for joining us on this episode of The Business of a Clinic. We hope you had a good time. We hope it was helpful. If you can think of anyone who should join the conversation, feel free to nominate them, send them our way. We'd love to invite them to participate. If you like what you saw, give us a like, share, comment.

1:15:23We hope we'll see you again next time. Thanks so much.