Episode Transcript
Daniel: What's up guys? Hope you're having a great day. I am excited to get into my conversation and share that with you today. I get to speak with Dr. Andy Burkowski and we had a great conversation. He is just a great example of someone that was dealing with a lot of these stressors and problems in the healthcare industry and what I think is unique about him is he had the courage to take a risk and create something new and completely sidestep the system and the way of everything's always been done, and go out and start his own practice and do it a very unique way.
And so we're gonna be talking about his experience. And ultimately how he realized that there was a major values conflict with the way he was being forced to run his practice in the traditional system, and how that ultimately motivated him to want to start his own practice, even though he was not like a lifelong natural entrepreneur.
So he shares his experience of what that looked like and how he tried the whole academic setup as a sleep medicine specialist and what didn't end up being exactly what he had expected. We discussed this culmination of events that got him to a point of having the courage to make the big change and face the fear. And get him to a point of realizing he had to leave the traditional system and start his own practice despite how the risks involved. He shares his own journey gaining financial literacy. And how that impacted him, being able to make this decision confidently and become a practice owner and really a trail blazer in the profession. And we discussed his experience starting a direct specialty care practice and we talk about why this is such a great model for providing the best possible care to patients.
And he shares how his life has changed for the better now that he is an entrepreneur and in control of the schedule. Make sure to check out the end where we talk about some of the resources you that might be of interest to you to kind of get you started exploring this path. So without further ado, I am going to jump into our conversation now.
Andy, thanks for joining me today.
Welcome to the podcast.
Dr. Andy: Oh, it's my pleasure. Thanks for inviting me.
Daniel: Yeah, I think I'm really looking forward to our conversation. I think we have a lot of stuff that'll be fun to talk through and you've had a very unique experience and, you've been able to navigate some of these healthcare challenges that are a lot of people are seeing.
But, I think what's really cool about your story is you did something about some of these problems. A lot of people just kind of get stuck in their problems. So you had the courage to kind of make a big change and go a different direction and now you're kind of like trailblazing a different way of doing medicine, which I think is especially cool.
So I really look forward to kind of talking through all this, but maybe before we get into all that, I think it would be good if you could kind of give us a little bit of a backstory on you. Like kind of how you got to where you are today and that sort of thing.
Dr. Andy: Right. Yeah. And a lot of this is very much on the things you've talked about in previous podcasts, particularly about, the rate of burnout, the unhappiness among physicians, the fire movement.
So I'll, be touching on all of these things, but one of the unique aspects and why I'm a good kind of match for this type of podcast is the changes to my financial life have actually led me to a career change. And I don't think those two are very much linked in my story. So I guess I could take you back to about four or five years ago.
So, I was working as a sleep physician at a very large academic center, and I was a few years into my practice and oftentimes changes are made through sentinel events. And I had a series of sentinel events. The biggest one is, out of the blue, I developed a life-threatening form of cancer, and this was back in 2018.
And so, for your audience, a lot of the things you've touched on, the time to get disability and life insurance was yesterday, because I basically had no health problems, maybe a little overweight, maybe very, very stressed out at work. So those were my risk factors. But I'm facing a life-threatening cancer and I'm not prepared financially for it.
And that kind of made me reflect both on how I was living my life in terms of what I was doing as a career, how I was spending time with my family. And that was probably my sentinel moment. I wouldn't be here where I am today had that not happened. And given that I am still here today, five years later, I survived obviously, but it was a poor prognosis, a rare form of cancer. And I had a 50% chance to be here in five years.
And through God's plan, I'm still here and I'm better off for it. What happened during that year, I was basically off work for maybe almost nine months and I didn't actually have disability insurance or at least private disability insurance. I'm married to a another physician, so my wife works very, very part-time as a pediatrician.
And our plan was, Hey, we're gonna just, if anything really unlikely were to happen, she could always just work full-time. You know, that? That's easy. She's the insurance, something happens to me. And, well, while I was reflecting on this during my year where I was basically in the hospital for more than a month and a half and getting chemotherapy and surgery, I thought to myself, "Well, that's bad because my wife's not working now and she can't take care of the kids because she's taking care of me and she can't work because she's taking care of me. You know, it would be nice to have a disability plan."
And we did have one through the university, but that was limited. That could have run out. In fact, it almost did run out and I had nothing in place.
And if that's not a side lesson to your audience, I don't know what would be, because I was a healthy person and all of a sudden I could be dead in less than a year. So, that's probably a common story for people who developed cancer. But I did not see that coming, obviously.
But fortunately, I survived the whole process and I went back to work in my academic practice and it really gave me a new perspective on things, particularly a focus on my personal health and my family life.
Because the biggest factor was, I think, the high levels of stress in my job were one of those risk factors for cancer, elevated cortisol levels. A lot of your physician audience will know all of these things that happen to the body when we're under high levels of stress. And being a sleep physician, I had always thought I'm going into the lowest acuity field in medicine.
Like all these disorders are chronic, they're lifelong, nobody's really dying of these things. There's no emergencies. And yet I was completely stressed outta my work and that gets me to the system. But before I talk about the system, I thought at that point, "Hey, I'm cutting back. I'm gonna cut to 75%. And you know what?
75% of miserable is still miserable."
Okay?
So it didn't matter that I had cut back from 100% to 75%, I was still almost working close to 50 hours a week, still working on weekends, even though I apparently got an extra day in a part of another day off. So it really wasn't the time.
Much less like what you're actually doing with that time. And that's really where things started to change for me because I was given a second life and I wanted to make things better the second time around. This was my second opportunity in life, and it turned out that I was focusing on a condition. A lot of these conditions, particularly the one I'm a specialist in, which is restless leg syndrome.
And restless leg syndrome is not valued in the insurance-based medical system. So at the academic center, even though I was an expert in this area, doing a lot of good work in this area, I wasn't really valued as a physician. I was pretty much overworked, not much time for research, not much time for teaching.
And I was kind of low on the totem pole, so I was not getting the good assignments in terms of teaching assignments and clinic assignments. So I was working really hard and I wasn't doing the type of work I wanted to be doing. I was doing research on Saturday morning and you know, here in Michigan it's snowing today, I was spending my 70 degree Saturday mornings in May. Instead of playing with my kids outside, I was writing research papers. And that's not what I thought I would be doing when I went into academics because part of the sacrifice of academic medicine is your salary. So the salary was close to the first or second percentile for this specialty.
So, and yet I was working as much as many other physicians who would make maybe two or three times as much. So I'm taking a financial sacrifice. I'm miserable, I'm not actually doing what I think I'm doing. I think I need a change of scenery.
Daniel: So that's like a direct conflict of your values.
Dr. Andy: Complete direct because I thought I would be doing a lot of teaching and research. And you know, the sacrifice for that is you go to an academic center, you take a lower salary to do that. But now I'm taking a lower salary, but I'm basically working private practice because I'm not doing any teaching and I'm not doing any research except on my own spare time.
So it really wasn't what I thought I would be getting into. And it turns out that that wasn't unique to me. As I'm sure some of your guests have already talked about, and the way the system is, even the academic centers now are becoming businesses. They're becoming businesses where they're making their product being medical services.
And their full goal is to make money. It's not to teach, it's not to do research anymore. And these are the most academic of centers if they're not doing it, certainly not the private hospitals and large physician practices are focused on teaching and research. So it was kind of a crossroad situation.
So I was at a conference and I was sitting next to a primary care physician at the conference. And I don't know why we were talking about it, but we were talking about preventative medicine and she told me, "Hey this was Dr. Taki, I could reference her, but she said, oh, I just started a preventative care practice.
It's sort of a lifestyle management practice." Nice.
The first thing I thought of is, "How can you do that? What the insurance isn't gonna pay for that? How could you even spend an hour talking to somebody about preventative healthcare?"
And she said, "No, I've started a clinic, it's called Direct Primary Care."
And this was a few years ago. I had no idea what this is. So getting to talk to her, she actually inspired me to consider going into this area. And so what happened was she had connected me with a consultant who sets up a lot of these concierge direct care practices. I was in talking to him about ideas and he thought this would be a great idea for me.
And he was right. It was a great idea. But what happened was, I'm sitting here with no life insurance, I had life and disability insurance, but it was through the organization. I didn't have independent life and disability insurance. So now I'm coming a few months off of a life threatening form of cancer.
I might not be alive in a year. Am I gonna go off and start my own primary care practice with no protection for my family. The financial, I guess it wasn't a mistake, it was like a financial lack of awareness back then caused me to change what type of career move I made.
So I said, that's a great idea. I can't do that. I need to take a job at a major medical center where I'm gonna get life disability insurance, I'm gonna have a salary. You know, an annual salary. I can't afford to take this risk. And so that's what I did. I ended up right before the pandemic taking a second academic job, and it turned out it was the exact same experience, if not no more extreme than the first one.
So it wasn't just the medical center, bad luck. I go to a second academic center. It's the exact same experience and I wasn't being valued for treating a condition that is not reimbursed.
Yeah. So
Daniel: like not having your finances exactly in order kind of puts you in a position to have to continue to conflict with your values, essentially?
Dr. Andy: Well, exactly. So if I had something as simple as life and disability that I could just carry with me into my own practice. If I dropped dead of cancer in three months, my wife and family are fine. You know, and so that actually made the decision. So I went into a second job, mostly because I didn't have my financial ducks in line.
Daniel: How did that deal in the moment like, .
Well, it..
Did you kind of, were you thinking a lot about that I'm assuming?
Dr. Andy: A little bit. I was that was the kind of the clincher in the decision. But I also thought, "Hey, I'm going to this new center. They promised me you're gonna, we're gonna focus on this area of research,
There were some hope.
Because I had only been, I had worked also at the VA so I had been in a VA system, an academic system, but I hadn't been to a second academic. So I thought, well, the second academic system's gotta be better than the first one. Right?
And it really was not, it was doubling down on every, you know, just a microcosm of what's wrong with medicine and the fee for service insurance based system that's going on.
At that point really, actually, right before I took that job, I had a friend. He was a friend from residency and then also had joined the department where I was working previously. And he's like, "Oh, you need to become more financially literate here, listen to this podcast. And one of them was called, you know, the White Coat Investor?
You've had Dr. James Dahle in the past. And so I'm like, "Why would he, I'm getting a new job. Why do I need to listen to this finance podcast?" And I didn't make the connection until maybe a couple months into it about how important this financial literacy would be to how you can, you know, the flexibility in your job and in your career.
And that one, and Ryan Inman's Old Financial Residency podcast. Those, I was starting to like gobble that stuff up in this transition. And that actually has what set me up for the next career change, which is what I'm doing now, which is starting my own direct specialty care practice. Because less than two, maybe a year into my second academic position, I knew that that wasn't for me at all.
And I thought about going to a third academic center, but then I thought they're all gonna be the same. It's really not a system that I'm thriving in. And maybe a background for your audience is, in my opinion, In each specialty, the entire system of insurance-based medicine is designed on the number of procedures you do, whether it's diagnostic or treatment procedures.
So it's biased to doing things for people that are measurable in this procedure. And we have procedures in sleep medicine. They're called sleep studies. But what are the conditions that don't involve sleep studies? Well, restless leg syndrome. It's a neurologic condition where there's no diagnostic test and there's no treatment that's in a procedure.
Insomnia. Insomnia is behavioral lifestyle changes. No procedure. Even a sleep study is pretty useless when it comes to insomnia. So you wouldn't guess these are two of the three most common sleep disorders, but they're completely neglected in our field. The number one treatment for insomnia is a therapy called Cognitive and Behavioral Therapy.
There's maybe 10 people in the state of Michigan that do this, and like 10% of the population has insomnia. So how can you have this first line treatment but nobody actually does the treatment? Well, because nobody's reimbursed for the treatment. It's all done by social workers and therapists. Not one physician that I'm aware of in the state of Michigan does cognitive and behavioral therapy for insomnia.
So you got this disconnect of the system with the actual science, the actual treatment of the condition. And that was true for my biggest specialty, which was restless leg syndrome. And because it wasn't valued, I felt like, "Hey, how can I serve my patients, particularly the complex ones who are being ignored in the system. I can create a practice where they actually would pay to get the treatment that they deserve."
And that's how I could reason it from a business standpoint. It's that the system, you could get certain care through the system, but these other neglected conditions, maybe people would actually pay outside the system to just get the treatment that's not available in the system.
And that's what I was banking on. And there were a couple funny days that really convinced me of this. There was one day I became this kind of, Regional expert in restless leg syndrome. So this one clinic day, I had two patients on the same day. One, she showed up in the room and she had a suitcase.
I said, why do you have a suitcase here? She's like, oh, I'm just coming from the hotel. I'm gonna fly back after the visit today. And she was from Florida.
And I said, "huh"
and you're Michigan at this point in time?
Well, so I'm in Ohio at this point.
Okay. Still.
So I'm in a clinic room in Ohio and she's flying in from Florida to see me. There are no other physicians in Florida that can treat this condition. So you're flying to see me, maybe instead of flying to see me, she would pay money to see me through telemedicine and not spend the time on the flight and the hotel fee, maybe. Next patient after that patient drove from Milwaukee all the way to Ohio, skipped all the academic centers in Chicago, Indiana, all the way to Ohio to see me in person outside of her state.
So, this kind of reinforced that there's this demand out there for good treatment. And maybe patients are willing to bend over a little bit, maybe bend over backwards to get it outside this system. So that was really the impetus. That's where I thought from a business standpoint, direct specialty care can work.
Because we had only heard about it really through direct primary care, which makes sense. You don't want a 10 minute visit with your doctor. You might pay a monthly fee to actually get good care for like an hour whenever you need it and have a personal relationship with your doctor, like how it used to be.
But for specialists, we do all the procedures, why would we need to leave the insurance system? But within each specialty there are these hidden conditions that are not profitable in the current system and they're ignored and neglected. And there's a huge market for that. And this was my business justification in part.
And so that's kind of where I got to the point where, "Hey, I could either take another academic job and it can be the same miserable experience, or I can start my own practice."
And I was actually inspired by my mother. So my mother started her own business toward her retirement years and got to coincide with finance stuff. But she's an investment manager, so I know half of your index fund audience is cringing. She's a portfolio manager, so she invests in stocks.
Small groups of stocks for people who are investing money. She started her own business. Long after the kids were out of the house and my dad was close to retirement. I said, why should I wait my entire career to start my own business? I can do it right now. My mom can do it. Why can't I do it? And my mom's still, she's at Fern Capital Management, she runs her own business still, like right now. So why can't I start my own business?
I've got my whole career ahead of me, hopefully. And so she inspired me to do this. So it was a constellation of things. It's these direct primary care doctors who I've been talking to, financial literacy, the fire movement being wise with your finances, but not a fire movement to retire immediately, but a fire movement to have flexibility in what you do.
Because if you have financial flexibility, you can take a risk and start your own practice. Because with my current direct specialty care practice, if I went out of business, guess what? There's a shortage of doctors. I could just get a regular job within a few months. Right. I'm not gonna be in big trouble, but if I don't have my financial ducks in line, I can't do that.
So that's sort of the confluence of the system being broken, becoming financially reasonable as an individual and being entrepreneurial. And I think that's possible for many, many doctors who are upset with the system.
Daniel: Yeah, and you've kind of described it well, I think it's multifaceted like it requires varying skill sets and they apply well to life too, like financial literacy.
I would advocate for anyone, whether you're starting a business or not, I mean, that's like, just a very foundational, healthy thing to do. And even having a focus on health and family, I think it's difficult for a lot of people that are like stuck in the grind and in conflict with their values to even get enough of a second away from that grind to even like think about like, what's most important and I'm actually aligning with it and how do I do something different to kind of get away from that.
So it's a lot of different factors that kind of have to come together and then you have to get prompted with these ideas. Like you said, you happen to be introduced to the idea sitting next to a colleague. I mean, that's fantastic to kind of get that. It's like the seed gets planted right there and then all these other things start happening that like germinate and you know, it's growing all of a sudden and then boom, you're rocking a business.
I think when you're looking at it on the front end, it's super scary. A lot of people, I think fear is the number one thing people deal with when they start. I bet people listening right now are like, "Ooh, that seems scary." But I would kinda take a step back, like the problems I think a lot of people I see going through in healthcare are also scary and in conflict with their values.
I mean, what's the cost of working in a environment that forces you to conflict with your values? Over a lifetime, I mean, over a career. I mean, that's huge. And when you kind of start to look at it a different way like that that can kind of get you that motivation, it seems like for you it was just a combination of factors that gave you that courage.
I mean was it your mom or was it a combination of everything that kind of came together to give you that motivation to kind of go into the unknown and take the risk?
Dr. Andy: Well, yeah, it was a combination because you can't do things where you don't have people who have gone before you.
I guess in some ways this is there in terms of direct specialty care. I'm only aware of about three or four sleep direct specialty care clinics and they're actually growing now. But there's not a lot of people in my specialty. But there were other specialists out there, the Direct Specialty Care Alliance had a listing of doctors and there were maybe six or seven at the time. And that's grown even since I started my practice. But I went to their website. I said, "Oh, wow. There's a cardiology position doing this. There's a podiatrist. These are procedural based fields." Yeah. And they still are finding a way to do well because cardiology's a lot of procedures.
But what about preventative cardiology? What about neurology that involves long-term management of things like migraines or other neurologic conditions that don't involve procedures. Rheumatologists who involve manage these chronic conditions that have no procedures involved. So I said, well, they're able to do that.
It actually was inspiring to see just a handful of people in the country doing this and then you obviously have the direct primary care groups that are, I think, growing exponentially, that there's no doubt that direct primary care is gonna work in most cases. But for direct specialty care, that's relatively even newer concept.
And with the patients I was seeing, I was restricted to these like 20 minute return visits. I even had a patient from Lexington drive up to Cleveland six hour drive in a 20 minute slot. You think the patient deserves a 20 minute visit, if she's gonna drive six hours to see me?
And I needed two hours with her. So I said, why can't I create a clinic where the patients get the time they need, they get the follow up and they get the correct management of their conditions. Because a lot of this is like, the conditions are being mismanaged because people just don't have time to see the patient, time to go over behavioral modifications of things that are time consuming and don't have time to read about the conditions.
Because they're onto the next patient, they see 30 patients a day. You don't have time to read about something new you ran into at the eight o'clock patient if you have an eight 15 patient right away. So that system was so oppressive to me, I couldn't just do a 20 minute visit. I have to have time with the patient to get it right.
And I talked to some of my colleagues from Fellowship and I said, is there something I'm doing wrong? Can I be super efficient and see these patients at 20 minutes? And they're like, "No, you can't provide good care without time, no matter how efficient you are." And the system that involves volume of patients is in conflict with high quality care, which you can't get around time, education, counseling, behavioral modification. That stuff is fundamental to health. And you can't be super efficient and get that done in 5, 10 minute visits face-to-face with patients. So I either had to compromise my care or find a system or leave the system. So what I did was I was thinking about leaving the system.
I had looked at non-clinical jobs like many people in your audience have done, and that be side gigs, but even side gigs as a full gig, that's become really popular unfortunately for doctors. And so the direct specialty care route ended up being the kind of the escapee valve. Yeah. And I'm almost a year in now and I cannot believe how liberated.
I feel like I'm, I am so excited. I almost wanna work more than I do when I used to drag.
Yeah. It's crazy.
I can't find enough time to work now and because I want to do, but I'm so excited about the type of work I'm doing. It's been great. So I don't know if you want to kind of transition into the type of practice I've set up or, you know.
Yeah. I
Daniel: mean I can so, relate to that for me, so I kind of had a similar experience in my career and what I had like a more of a ultimate like when I came to grips with this idea in my head it was over, game over. And the idea was that I realized in financial services, the traditional system, that I couldn't provide the best possible advice for my clients.
And there was an alternative where I could do better. And when I kind of came to that realization, I'm like, I'm out. I gotta go today. You know? So it was very quick after that realization, because I think most physicians I know are very dedicated to like the patient and taking good care of them. And I think if you can come to that realization and I mean in some cases you are able to provide the best care.
I'm not trying to say physicians aren't able to provide the best care, but in a lot of situations you're not. And if you can admit that to yourself the system is not gonna want you to admit that. I don't think because there's an incentive to continue to have you there. So you have to do that hard work yourself. It's a complicated thing. I mean, you have to look at yourself, you have to look at your finances, you have to look at what's most important.
And that's why your story's so great, you kind of had all these experiences and looked at all these different areas of life and you had this wake up call too that was kind of like a second chance at life, which, you know, really, I'm sure really emphasized that importance of time is, you know, life is short and you never know what could happen.
So what's the point of working in a terrible job that conflicts with your value? Especially if you don't have much longer to live. I mean, family, I know you've already said family's important and you know, you gotta carve out the time, but now it sounds like you're on the other side of the coin.
And that's what I've heard this story over and over again. It's like when you can get in a place where you professionally start to love your work, then it's totally different. You still have these pools between like life and family and all these different values, but like the work thing is pulling at you because you love it and it's re-energizing almost.
And you know, it's not like it solves the whole balance thing. And it's not like perfect at by any means. It's still stressful, right? I mean, your job now is stressful still, right?
Dr. Andy: Oh yeah. I mean it's any high intensity job physicians, lawyers, you know,
everything.
Financial management, whatever it is.
I mean these are difficult jobs for a reason. It's not mundane, monotonous stuff. It's a lot of thinking, a lot of intellectual stress throughout the day. But if you're miserable doing it on top of all of that, it makes it difficult. And why, as medical professionals, why is everybody seeking to leave as fast as possible or, you know, that's the issue.
The fire movement is great, but some part of it is a symptom of why are we went into this field to get out of it as fast as possible.
Daniel: Yeah. I think it's kind of sad, honestly. Like I feel every time I see someone really going hardcore fire as a physician especially, or really any like super specialized field, I'm like, it's kind of sad that somebody that's like a rockstar that's become like a super expert awesome at one specific particular area of life is working as hard as they possibly can to get out of that.
I mean when you look at it that way, right. To me it's like, "Man, that's kind of
Dr. Andy: a, that's sad.
In medicine, it's the disconnect between what people think they're going to do when they're physicians and what the system actually does for them.
Correct.
So I don't begrudge any physician who does fire because they were told the bill of goes, I thought I envisioned my career completely differently as an academic doctor than what I got. And it was because the system is just so business oriented now. And healthcare is not really a product. It is a product in some ways, but it can't be purely just to make profit.
Like, we're not selling cars here. This is people's lives. It's their health. There has to be some financial sacrifices. Even by these big corporations, these billion dollar hospital systems, they need to make sacrifices both for teaching, education and research, but also patient care and their physician wellbeing.
So with the burnout and everything, the burnout is really a symptom of that doctors maybe are in the right profession, but the system in which they have to practice their profession is not ideal.
I'm not blaming doctors for fire. I'm blaming the
Daniel: system.
Correct. I agree completely. It's the system. It's just sad to me that these people that are so good are kind of being forced out by the system. But there is a different route and possible, and that's why entrepreneurship is so fantastic, is it's like clean slate. You can kind of create whatever you want and start to solve problems.
That's the difference I think, between the stress running a business versus like working in a system, being a cog in the wheel, like when you're running a business or involved in a business where you have a say so, is you are able to solve the problems or deal with the stress or manage it or like do make changes that like help make progress.
It's different, I think to have stress that's like recurring, like same old problem, never gets fixed. Same old problem, kind of stress.
That's like, makes you go crazy, I think versus in business you can be like, oh, well we're having a problem with, you know, maybe I use an online scheduler. Which is kind of cool in itself compared to the system because you're doing like old school scheduling on a landline or whatever, but maybe that's having a problem, so let's change it to the new version or whatever.
I mean, you can change these kinds of things in your own business, which is fantastic. I mean, like I said, a different type of stress. But yeah. Maybe if we can get into like the business itself, I would love it if you could kind of describe maybe like from the patient's view, how does the experience compare for them going to what you were doing before versus like how does it compare now?
Dr. Andy: Well, yeah, I think, well the feedback I've gotten has been great. No one has left my practice except for a few patients who are doing so well. They don't need me anymore. Perfect. Nobody's left because they're unhappy. And it's not that I'm a different doctor, I'm the exact same doctor I was at the academic center, but my first academic center, I would see a new patient with the most complex sleep disorder and say, "Hey, I'm gonna start you on this treatment. Oh wait, I don't have a follow up spot for five months. "
So I'm starting them on this treatment. They're gonna have side effects from it. They're gonna need the dose changed, and they're working with a medical assistant, a nurse, back and forth through these messages while I'm just seeing patients all day. And I can't, so I either take my evenings calling people or the medical assistant is handling the case through these portal messages.
And that's just, it doesn't work that way. And so I've set up this system well, with, through direct specialty, you're not reliant on cramming your schedule full of patients to get them in. So you actually have this fluidity in your schedule. So there are some days I don't actually see patients at all, but I, I contact 15 to 20 of them, who, some of them I talk to every week.
There's some patients who might send me a text message several days in a row. In the current healthcare system that's based in insurance, who does that? Who can send their doctor a text message? They don't even post the doctor's emails on the internet. They don't let you even email, you can't find anybody's email on the internet because you gotta go through these portals and then the portals reviewed by a administrative person, then it goes to a nurse. But if I have a patient who has a question five minutes after their appointment, they can send me a message and I will respond to it.
So imagine being a patient like, Oh, this doctor, he just spent 90 minutes with you and you still have five follow up questions.
You can just send him a message, he'll get back to you that same day. Maybe even that same minute. And so that's the kind of responsiveness that people should have . It's just not in this current system where once your 15 minute visit's over, "Hey, schedule your next appointment three months out."
And it just doesn't work for some of these conditions.
And in the case of restless leg syndrome, in some ways it's set up my business plan in that the majority of patients with restless leg syndrome are not being managed correctly because the treatment guidelines have changed over the past 10 or 15 years. And the treatment that had been used for this condition actually makes the condition worse.
So we have this population of 5% of the population is restless leg syndrome. Geez. And it's being mismanaged by probably 70% to 80% of physicians. And there are no physician groups, no sleep clinics that want to handle these patients because they don't make them any money. So you've got a large number of patients who are doing badly, but they can't go anywhere to get help.
So voila, you can pay to get help. I've started a clinic where you can get help in certain states of course, but I can't be in every state. But in the states where I'm licensed now, you can come see me, but you have to pay and not everyone wants to pay, obviously.
Yeah, but
Daniel: it's not upset. They're very reasonable prices. I think a lot of people can afford or really, I'm not gonna say anybody, but like, it's not..
Dr. Andy: Well what's interesting is the, it's sort of an addiction to insurance. So that it's almost like insurance is the law and if you go against insurance, it's against the law.
And one of my examples is, there's like a $7 medication, but it's not covered by insurance. And then the patient will think that they can't get the drug because their insurance won't cover it. And I say, "Well, you could just pay cash, it's $7." But then they think, "Oh no, I pay all this money for insurance.
Or I have Medicare and I paid into the system for 30 years of working and Medicare won't pay for this. What do I do?"
And it's this system that's outside of market-based economics where you could actually just pay to get it done. And it's not even that expensive. And the reason it's not about how much money people have, because I talk to professionals who probably some of them make a lot more money than I make who say they can't afford my service.
Or I'll get the patient who says, "Oh, you're charge of membership fee. I'll think about it after I get back from my Mediterranean cruise."
So there's this disconnect between valuing health. We were so addicted to insurance. We don't even know how to monetize our health. For a couple hundred bucks you could see a direct primary care physician and you could get these conditions under better control long term, but "Oh, it's not covered by insurance, so I'm just gonna stay with, you know what I'm already doing."
Yeah. But that's
Daniel: backwards how insurance works. And other, I mean like in my view, I've like studied how insurance is supposed to work and it's supposed to work for catastrophe coverage. Like that's where it's efficient insurance. When it starts to get into like nickel dimi stuff, it's super inefficient because for example, on, like your car insurance.
Like if you ensure door dingers for your car, then that forces the insurance company to have to deal with that. And they're gonna charge you for it ultimately. And they're gonna put their 25% premium on it because they have to charge you for profit, they have to build in the profit.
And then there's gonna be all this administrative fat that gets built into it. So essentially if you're running your door dingers through your insurance through the car, add like 50% plus cost to it to be able to do that. And so what you want with car insurance, you're like, well let's try to get the deductible higher so that I can handle a door dinger on my own.
Oh, exactly. I'm Sure that not a problem, but like if it's over $2,000 or whatever the number is for you, like that's when we use insurance because it's kind of like starting to negatively majorly affect my financial situation. But healthcare, for some reason, people have gone the wrong direction. It's like, let's cover a hundred percent of everything on health in insurance and nothing out of pocket. Or at least everything has to run through insurance. But then that always increases your rates.
Dr. Andy: And you've hit on, in fact, I had an insurance guy, a retired insurance guy. He was asking me about this whole system and I gave him that example is you're not using your auto insurance to pay for the chipped window.
Why are we using our insurance to pay for a $100 primary care visit? You should be using insurance if you get cancer and you have a $300,000 hospitalization. So that's exactly correct. And I don't know how the system got here, but, it's gotten to so extreme that you have insurance micromanaging a $7 drug, I gotta submit 30 minutes of paperwork to get a $7 drug approved.
What system does that make sense? Where you've got a doctor having to waste and doctors don't waste their time doing it. They have to hire people to do that. So now you're paying people. To submit 30 minutes of paperwork for a $7 drug. It doesn't make any sense in the world. And I've done that myself.
I have a very high deductible plan because the emergency fund that you should have can cover any of these minor, minor fees. You don't need to nickel and dime the insurance to get these minor things treated. It's really, insurance is ensuring for catastrophic events. It's not for ensuring for every little thing.
And so I think that system, which was well intended, I don't know, historically, wasn't it to be a benefit when salaries were capped? They gave this as an additional work benefit, but we'll throw in some health insurance so that in decades, that has spiraled into the insurance is gonna manage every little thing.
Well, what happens if the insurance doesn't know how to manage a condition? Maybe the doctor knows more about how to manage a condition than insurance. Back to my field again, the first line treatments for the conditions I treat are not covered by insurance. Why is that? because they're behind on what they're covering or they choose not to cover it.
But why do they get to make that decision? Isn't the insurance supposed to be working on behalf of the patient? Not against the patient? That's kind of where we're getting with this is, it just doesn't make sense in any way.
So
Daniel: with restless leg, they're the traditional system.
Most physicians are not managing it correctly and for various reasons it's not getting much attention, you know, time wise because of the financial it, you know, it's hard to monetize that in the system. What does it look like for you? What is the actual management of restless leg? What should it look like as a particular condition?
Dr. Andy: Well, I mean, what research has shown in the past 10 or 15 years is that is a condition where there are low iron levels in the brain. And for those who don't know, restless leg syndrome is this neurologic condition where people have the urge to move their legs.
So it can be very devastating because it can just disrupt their sleep. It could, you know, just make life miserable for them. So the problem is, there are these drugs that came out 20 years ago called Dopamine agonists, but it turns out that with long-term use, they basically make the condition worse over time and they cause drug dependence. So people can't just stop the drug, otherwise they have severe withdrawal.
But doctors are still prescribing these drugs at a rate of 70%, even though the guidelines changed in 2016. But why haven't doctors picked up on that? Because they don't have time to pick up on these changes.
There's no interest. You go to the conferences, there's no talks on restless leg syndrome. The American Academy of Neurology doesn't have any talks on restless leg syndrome this year.
I was at the American Academy of Neurology's conference last year. I was the only one who gave the talk on restless leg syndrome.
American Academy of Sleep Medicine, almost no talks on restless leg syndrome this year. Why is that? There's no money in it. Nobody cares about it, not life-threatening. And 5% of the population has it. There's a disconnect. There's a supply demand disconnect there. There's 5% of the population who need treatment for this condition, and no one's interested in treating it.
So there should be a financial solution to this. People should want to pay to get treated for the condition that's not available. It's a scarcity thing. And that's basically that was the foundation for this clinic. So now I've set up a clinic where patients pay a consultation fee to see me. I can give them up to 90 minutes of my time, sometimes more than 90 minutes with just the first consultation.
And we can assess everything that there is about their sleep in that 90 minutes, probably three times more than any doctor's ever talked to them about. And then if they choose to become a member, they can pay a monthly membership fee. And I can have an ongoing communication with them indefinitely. So if they need to talk to me next week, I'll talk to them next week, they need to talk to me two hours after my visit, I send 'em a message to clarify what I said during that 90 minute visit.
That's not something I think anyone can find in an insurance based system, but if you go to these direct primary care or direct specialty care clinics, that might be actually quite feasible. And so I set it up.
I have complete autonomy over my schedule. I can do that and. . So it's really helped out with patient care because now I can set up the schedule the way the patients want, where I can communicate with them, follow up with them, and I can be on top of the guidelines. because if there's something I don't know, I can, I have time to look it up. And know it, "Oh wait, the guidelines just changed in 2018. I should be doing this instead. Because now I have time to read on behalf of my patient. And so that's kind of the beauty of this system, it's not one that every patient values though. As I mentioned, but I think the tide is starting to change and the more growth that occurs in this direct payment area, the more it'll be more acceptable to pay for your own healthcare, because we pay for everything else. I mean like plumber comes to your home, you're not billing the homeowner's insurance, you're paying the plumber when the plumber leaves your home. That's your choice. You could have a leaky sink or you pay the plumber.
And so that's what direct care does is it really gets it back. You've cut out all the middle men. So the decision making is the patient and the doctor, which is how it used to be a hundred years
Daniel: ago.
Yeah. It's back to the old school. I mean it's back to the basics. Very simple. it's like I pay you, you give me service. I mean, it's fee for service basically.
Dr. Andy: Right.
And you're right. I think my fees are reasonable, but I don't have much of a way to compare myself because it's so unusual.
There's nobody doing it.
I'm on the side of thinking I'm not charging enough at this point, but what I did was when I set up my clinic, I compared myself to these other specialists in the country, even though they were in different fields.
Oh, well if they're charging that for a 60 minute visit, maybe I should charge this for a 90 minute visit. And so you, there's sort of a market, but it really, I could charge five times as much as I am, or one fifth as much. I don't know. But it, there's a lot of flexibility there because you are the doctor who sets up the clinic.
You have autonomy over that. And that's really the emphasis is the autonomy has been the part I'll give you an example. Like my son, his fifth and sixth grade basketball team needed a coach. And it's like 3:13 to 4:30 Monday through Thursday, what working individual is available 3:15 to 4:30?
Hey, I just blocked out my clinic from 3:15 to 4:30 the whole week. I'm coaching this fifth and sixth grade basketball team. When would that have ever happened to an employee
Daniel: system?
Which is awesome, especially in medicine. I mean.
Yeah, it's incredibly challenging, but that's what life is about.
I mean, that's good stuff right there. I absolutely love coaching my son's soccer teams. I mean, that's just been good experience but you have to be able to have that margin in your life. And a lot of people don't have any margin and don't have any control, and it's impossible in that situation.
Dr. Andy: Right. And that gets back to finance and that what you're valuing because the way I've set up my clinic, I work three days a week for clinic, strict clinic work. So Tuesday, Wednesday, and Friday, and the other two days, I'm a homemaker. I am at home. I'm homeschooling one of our kids. I'm cooking, I'm doing dishes.
And my wife's working those two days and guess what? The three days I'm working, she's not working. So we essentially work one job between the two of us and we each get to have time at home and with our children. But none of these large medical centers will allow that. They require everyone to work 80% and probably the reason is because no one would work 80%.
Everybody would work 50% if they could. So they couldn't possibly do that. But you can't really find centers that will allow part-time work, even though it's perfectly reasonable you. Open up the clinic part-time or you work a certain number of shifts. It's very easy to work part-time in medicine because everything's piecemeal.
It's not like you're working on a big project where the project's gonna stall if you're not working. Everything's based on these groups of visits and you could really have any schedule you want. And that's what I've set up. I have a 60% schedule and there's no harm in doing that to me. So yeah, it's just that level of flexibility, autonomy and then doing what I like to do.
So I've been doing a lot of work in research and I've done more research this past year than all of the seven years in which I was in academic medicine. I've got my first abstract in seven years that was accepted to the annual meeting. I'm working on a very large publication that I'm publishing.
I'm working on the clinical guidelines on that committee. So I'm putting in all this work into academic work, which I never had time for when I was in academics. It's just unbelievable , like I'm doing all this academic work. I don't, I'm not affiliated. I don't even have access to a library or anything because I'm just in my home office doing research.
So those are things that people don't think of is how else they can spend their time side gigs. There's so much variety and flexibility if you're an entrepreneur, you have your own practice, you have your own autonomy. Yes, you're right. It gives up the guaranteed salary.
High, high salary, high benefits, but if you can get your business to work, it just, it's a fuller life. You can just do a whole lot. And now I can go back to saying I'm gonna work till I'm 70 again. Yeah. Instead of retiring as soon as possible.
Daniel: So, well, maybe we can make the case for entrepreneurship a little bit more enticing. I think I can sell it pretty good. My favorite selling point for entrepreneurship because I think the common, most common concern is this guaranteed salary. And if I go, because I think a lot of people probably resonate with what you're describing. I would imagine just based on the pain I see in the system.
But there's this fear around giving up the compensation. And that's real. But what I would argue is that if you look at well first of all, there's a demand for the system has gotten so problematic that there are people, patients, I'm talking about that feel the pain too and want to pay good money to do it a different way.
And when you have like 150, or I don't know how many patients you have, but like, not, not 7,000 like you would in a hospital setting, but like, you know, 200 patients paying you to do your service or whatever versus one hospital employing you, that's actually more risky working for one, like the hospital can fire you in a second.
Dr. Andy: Like we saw that with Covid, we saw that with layoffs, salary reductions.
In the
Daniel: worst possible time that you could think of, but like in a business, you have to get fired by 200 people. And that's not gonna happen. Especially because you're able to take better care of the 200 people than you were before.
And you know, it's common sense. So I think it's scary and intimidating. And there is risk on the front end. I mean, like, you gotta build the thing. It doesn't like happen overnight. That's where like the financial literacy stuff really kicks in, right? It's like you can make a plan for that kind of thing.
And plan out your finances to where it's pretty low risk. Like if you have, you know, the basics, like you got a cash reserve to some extent to kind of give you a runway and then you get the insurances taken care of and you get the backstops. It's not, when I started my business, I fully expected to not pay myself for two years.
That was like part of the plan. Right? Right. And it was just like, then it was no big deal. It was just like we're not making any money the first few months but that's because you know, you're getting going and getting started and that's entrepreneurship I think is fantastic for problem solving. And there's so many problems in healthcare and I think, I wish I get excited when I see new physician entrepreneurs because I think it's just one more person solving some of these problems.
But it is scary. I mean, has that been your experience? It was scary, but it was not, it was kind of just one of those things that, you know, ended up being part of the plan and you know, your finances help you work through it.
Dr. Andy: Well, yeah, I mean that's a great point is that security and it's a false sense of security because a lot of doctors are making so much money that they actually could cut back quite a bit and it wouldn't make any difference to their lifestyle at all.
And because I would talk to some physician, like, you know, I was working 80% at my last, and I'm like, what? Why don't you cut back 80%? You get an extra day off. "Oh, I couldn't do that. You know, I can't afford to do that."
I'm like, "How could you not afford to do that? 20% of this six figure salary is still a six figure salary." And that's way more than the average American makes. It's not a huge cutback.
So there's this
Daniel: mindset, it's more of I don't want to do it. I mean, they could,
Dr. Andy: right?
But they don't realize that it really wouldn't change a whole lot. A lot of people would not have to cut back all that much to cut back 20%.
And again, I didn't say that that was either the solution for me, because it didn't, cause I cut to 75%. I was still miserable. So it wasn't the time part, but it is this fear. But we're in this artificial environment where the healthcare system, there's a bottleneck of physicians getting into medicine and there's far more people retiring and leaving.
So there's a shortage of doctors. So physicians are the least likely to be out of a job for very long. You might have to move to a different city, potentially that could be not very good, but there's gonna be a job that pops up in your neighborhood every few months, even if you're a specialist.
So, I don't know. That's the security net, right? If this is,
it's the backstop. Yeah.
So I said I'm gonna be at my desired salary level in two years, or I'll just get a regular job like I was gonna do anyway. Right? So that was the security is that I could just get the job that's sitting there waiting for me anyway if my business fails.
But
Daniel: the upside of doing what you're doing is you get to do something you love and provide better care to patients and create something unique and spend more time with your family. And like all those things are priceless. Like you can't put a price on those things.
Dr. Andy: Exactly. And it's not a one particular pattern if you have a solo practice, you're running your own business, you could set it up however you'd like. If you wanna make a ton of money and you work six days a week, you can choose to do that, but it's not somebody forcing you to do that.
You can decide to do that. If I set my clinic days to three days a week, I could do four days a week. If something happens, kids are in college, I need more revenue. I could work five days a week, if the kids are out of the home. It's whatever you want. There's no right or wrong when it's you.
You can design it and there's the flexibility there to set it up how you'd like. You don't have to do research. You could see more patients, you could do all these other interesting side gigs, things for fun. But that's the beauty is really the autonomy. But then you get so much satisfaction because you're really making a huge difference for the patients you're seeing.
Yeah. In a way that you couldn't do before. Like, I'm the same doctor. I know exactly how much I knew two years ago, but now I'm, I've got this environment now where I could spend a half day with one patient and just completely revolutionize their care for t hese sleep conditions and that would not have been possible before.
And I'm the same doctor. And I'm a much happier doing it this way. And if you don't want to have 90 minute visits, you don't have to do that. Yeah. That might not be your style. Like you said, there are personal values to each thing, but it's the option to do that. And in medicine, we're in this high functioning, you know, we could have done all these things engineering, we could have done business or consulting. We chose to go into medicine and then we're basically an indentured servant to this major medical corporation and we're miserable. And we just, we're selling ourselves short by giving into that kind of system, out of fear of, "Oh, I'm not gonna have a salary."
You have talked about it on your podcast with these practices getting bought up and controlled by more business entities. All the major medical centers are buying up all the practices in the area. This is getting worse in some ways, but then you've got this organic growth of these direct care groups and concierge practices where it's going in the opposite direction.
And that's what I like to see it. It's really seeing that side, that's the balance between all this corporatization of medicine. And that's giving doctors a second life, I think.
Daniel: Yeah. I think it's the future. It's definitely got a lot of growth, huge growth potential. As we start to wrap up, I wanted to talk about a little bit more about entrepreneurship.
I know we talked about this when we were chatting the other day, but I know you didn't exactly consider yourself an entrepreneur like, you know, early in your life. You know how some people are like, I'm an entrepreneur, I'm for sure, early on, and they kind of call themselves an entrepreneur.
A lot of times physicians I speak with are not, they say something like, well, I could never be an entrepreneur. Or, like, I don't have the skills or the personality to be an entrepreneur. What was your experience like in regards to entrepreneurship? Did you feel like it was kind of a personality skillset that you didn't realize you have?
Or was it more been like a learned skill or what's that been like for you?
Dr. Andy: Well, it's a 180 as to what I thought I would, I never wanted to be leading anything or starting anything. I thought, "Oh, I love just following orders and just being in this system that's well organized and well structured and I can just do that over and over again" is very comforting for me at least to follow, you know, this very structured environment.
I love the structured environment and in training you got medical school, residency, sometimes fellowship, everything's dictated for you. So you're in this very structured planned environment and then, "Oh, I gotta start my own practice all of a sudden." That's hard for most physicians because you're in the complete opposite system.
There's no mentorship because all the doctors you're learning under are mostly academic. You do to get some community. Some people rotate with some community physicians who have private practices, but you don't get that exposure. Everything is very dictated toward you through the big system.
And I thought I have to do academics. I have to be part of a big system. I'm gonna be this very specialized doctor. So if there's no reason to think I would go out on my own, I never thought I would do that. And one of the things that doctors sell themselves short about is their ability to learn and synthesize information.
So you know, if you can make it through medical school where you're studying like 12 hours, 14 hours a day, all this memorization, all this, if you could do that and just apply it to finance or apply it to a couple books about how to start your own business. Imagine how quickly a doctor can look and that's been my experience is like I put my medical energy toward let's learn finance.
I can listen to a handful of podcasts while I'm cooking or exercising. I can start to really educate myself very quickly on something I knew nothing about, no business skills, no classes, never. I didn't even have a lemonade stand growing up and now I've started my own business. Now I've got a couple businesses, small businesses going now, but I learned that stuff very quickly because I am trained to learn things very quickly.
That's part of being a doctor and doctors, obviously to become a physician, you have to be very intelligent, have a great work ethic. You apply those trait, those can be applied to entrepreneurship because entrepreneurs are not just, 'Oh, he's got a personality or he created some great idea." Yeah, that can happen, but these same skills are what make entrepreneurs good too.
So you just have to transition those and apply it to just a different area. And that's what I've found. And I, yeah. I'm not running a 500,000 employee corporation. I'm an N of one maybe two ends of one now, but that's really a lesson to everyone is that this was not on the radar three years ago and now I'm running my own practice.
So I went from one of the largest sleep centers, sets of sleep centers in the country to a solo practice with no employees and it's worked out extremely well.
Daniel: Yeah, I love your story. I think, I agree. I think physicians have a lot of the natural skills already that are beneficial in entrepreneurship and you're kind of like ahead of the game.
The average person doesn't, takes a while to learn these things, and you can kind of do it in two days. Listen to the podcast all night. I mean, that's like a shortcut almost. And being like the smartest types, that's a huge benefit. And problem solving is huge. I mean, being able to solve problems, that's what entrepreneurship really is looking at a problem and kind of coming up with a good solution to it.
So I love what you're doing. I really appreciate you coming on. For people that have, I have a feeling there's gonna be questions about like direct specialty care or I think direct primary care has kind of gotten to be a little bit more well known, but do you have any recommendations for like, resources or places to learn more about how it works or what it's about or those sorts of things in regards to direct specialty care?
Well, yeah,
Dr. Andy: there's a growing website, I think it's called Direct Specialty Care Alliance. I think it's dscalliance.com maybe. But that's where Dr. Garita, I think is the one who had set up this website and I went to that website initially. There maybe were a half dozen or maybe 10 people on it, and there might be three or four times as many now a year later.
And just working with other physicians, but a lot of the direct primary care stuff the DPC story podcast, some of the Direct Primary Care Alliance, some of those groups, you can apply a lot of that material to specialty care. You just have to envision what your specialty care will look like within a direct primary care model.
There's some differences there, whereas I'm not seeing general patients. I'm, I'm very, very specialized in certain areas, but that has its own niche. And so my visits are more intensive. I have fewer patients, but maybe charge more than say, somebody who might be just doing general work within their field.
So it has its own flavors, but you can extrapolate a lot from direct primary care. And so the Direct Specialty Care Alliance, I think they've got a Facebook group. And so meeting other physicians and working with other physicians is a good way because people mentoring other doctors is a great way to learn. And that's how I was introduced to, I'd never heard of Direct Primary Care before four years ago.
Daniel: Yeah. Okay. We'll definitely link to those in the show notes and your website for your practice.
Dr. Andy: Well, so I relacshealth.com. Relax, Feld, r e l a c s health.com. Is my clinic website. And so that's where patients go and they can book their consultations right there.
And people wanna see how I've set up my clinic. Everything is transparently there. I do all the work myself. I don't hire people to do the website because I learn how to sort of build a website on my own so everything can be learned. It doesn't have to be the best because you're, what you have to be the best at is being a doctor.
Everything else can be, you know, just enough ,
Daniel: so.
That's a lot of what entrepreneurship to is learning to kind of minimum viable product is, I think that's what they say, let's get this thing, just good enough to release and for websites. I agree. That's a good example.
But yeah, thanks for sharing that and we'll definitely link to that as well. And thanks for coming on. This has been a fun conversation. I love talking about this stuff. I could talk about it for days and days, so, but I know
Dr. Andy: The work you're doing is great because if I had have that in like medical school, your podcast for example it probably would've changed my career, maybe earlier than was changed because that the financial literacy makes a huge difference to physicians.
And and I talked to in-laws and things who are going into medicine, I tell them that this is what you need to know. It's might not seem germane to medical care right now, but you'll see as soon as you get out and practice how, what a difference it can make to your career and your life, your lifestyle.
Daniel: Yeah, it's huge I agree. Well, Andy, I appreciate it and we'll look forward to catching up soon.
Dr. Andy: All right. Thank you.
