Wildest keynote! Singing and dancing across stage with 4000 doctors in Las Vegas. Rowdiest audience ever (at a medical conference at least). Read transcript and/or download & listen to MP3 below:
. . . And now what we have all been waiting for, our keynote speaker on today’s theme of mental health. I give you Dr. Pamela Wible. Born into a family of physicians who warned her not to pursue medicine. Dr. Pamela Wible soon discovered why. In order to heal her patients she first had to heal her ailing profession. Fed up with assembly-line medicine Dr. Wible held town hall meetings and she invited citizens in her community to design their own ideal clinic. Open since 2005 her community clinic has inspired Americans to create ideal hospitals and clinics nationwide. Her innovative model is now taught in medical schools and hundreds of ideal community clinics have opened all across America even into Canada and New Zealand. An inspiring leader and educator of the next generation of physicians, Doctor Wible has been named one of the 2015 Women Leaders in Medicine and the “Physicians Guardian Angel.” Thank you for joining us Dr. Wible.
To be real. It’s got to be real. All right. Wow. How refreshing is it to be in a room with 4000 independent innovative thinkers who are disrupting the medical system. Let’s hear it for you guys. And this is a medical system that needs to be disrupted because our medical system (as you know) is endangering the lives of patients right now—and physicians. Think about it. How weird is it that with the highest suicide rate of any profession how can physicians actually lead a longevity movement. Does that make any sense when we’re losing so many of our brothers and sisters to medicine?
Among medical trainees suicide is the number one cause of death today. I’m pretty much steeped in this topic. It wasn’t necessarily clear from the introduction but I’ve been running a suicide hotline, a free suicide hotline for doctors for six years. I’ve spoken to thousands of suicidal doctors. I have a very deep understanding of physician psychology and I have personally investigated more than 1100 physicians suicides. But not to worry, my talk’s going to be really inspirational and uplifting because weirdly through the process of investigating all of these suicides I happened to stumble upon the fountain of youth for physicians—an anti-aging elixir for all health professionals.
What I discovered is more potent than any kind of hormone you could prescribe—and works faster. Even though I’m a big fan of fasting this is way better than any of the fasting protocols. In fact, with this fountain of youth that I discovered for health professionals you might as well just skip the vaginal rejuvenation and forget about stem cells for your erectile dysfunction. When I share this with you your libido will go through the roof. So anyone interested in this? Raise your hand if you’d like to know. All right. Here we go.
It’s about finding your bliss. So at one point you actually felt a lot of excitement about pursuing medicine. Some of you knew since you were three, four, five, even eight years old that you were destined to be a healer on this planet. You were so excited. You dressed up like a doctor for Halloween. You told all your relatives you’re gonna grow up and be a doctor—and you became a doctor. I know many of you were super excited when you got your acceptance letter to medical school. Does anyone remember like how exciting that was?
But then after that we went through this indoctrination process. I think a lot of us lost touch with this bliss thing. And so I want to just share how you can get your bliss back. But first I want to ask . . . there’s probably some of you that are super blissed out in here. I need to figure out who you are so I have three questions that I’m going to ask but you can sort of just privately honestly answer to yourself.
1) Are you the type of person that’s like super energized, like you cannot wait to get to work on Monday morning? Is anyone already like that? (laughing) Just keep it to yourself right now but think about it. Are you the type of person that like jumps out of bed before your alarm clock goes off on Monday morning, can’t wait to get to work?
2) Are you having so much fun at work that you would do it for free? Everyone’s laughing. All right. That’s the second question. (still laughing)
3) Do you love your job so much the thought of retiring is horrifying? You just don’t want to retire. Has anyone in here answered yes to all three of those questions? (laughter) Raise your hand. Whoa look at that. Look at that.
There are people that are super insanely blissed out right now. Take note. These are people that should be on stage next year because they have something to teach the rest of us about why they’re so excited. Okay. How many of you answered yes to at least one of the questions? My goal is for all of you to answer yes to all three questions. This is not like a made-up fantasy in my mind. People are actually feeling this way. I’ve met and helped hundreds of nurse practitioners, PAs, physicians recapture this bliss and I want all of you to feel it too.
But I believe what obstructs us from being able to do this is many of us think that we have something called burnout. If you feel like you might have burnout or you’ve had burnout in the past just raise your hand if that’s something you think you struggle with. Because what I’m going to do here is help everyone beat physician burnout. I have like a super-quick solution! In three minutes we’re gonna just get it out of your system—kind of like a group colonic cleanse—we’re just going to get rid of it. (laughter)
Honestly (I hope you don’t mind if I curse) I think burnout is bullshit and I don’t think it really exists, it’s a made-up term. I don’t know if you know the history of the word burnout but let me just tell you burnout is slang for end-stage drug addiction in 1972. Isn’t it weird that now we’re labeling the majority of doctors with burnout in 2018? Does that make any sense at all? Doesn’t make any sense.
Physician “burnout” is actually a misnomer. I think it’s a label that people turn to because of mental health stigma. They didn’t really want to say they’re depressed or suicidal so they’re were burned out. Psychologists popularized it on Oprah and TV and everyone was burned out. Housewives were burned out. Waitresses, everyone was burned out. This word holds no real precise meaning. It’s just a trash can label—not really even a diagnosis, a made-up term that is used as psychological warfare on physicians to control us. I’m being real. Telling you the truth. Victim-blaming term.
That’s why I don’t use it because on this suicide hotline that I’ve been running when I talk to physicians and I ask them when they first felt like they became suicidal or things weren’t quite right, it’s when somebody told them they were burned out or inefficient or somehow they were labeled as not fitting in. When those sorts of thoughts start spinning around in your mind you think well maybe I don’t fit in and maybe there’s something wrong with me and maybe I’m just not going to make it as a doctor and maybe the world will be better without me. This victim-blaming term is not helpful. We’ve been talking about burnout for like four decades—with no solution in sight. The reason why we don’t have a solution is it’s a misdiagnosis and a bullshit term. So the quickest way to get over burnout is to stop using the term because it’s a cover up for something much more serious going on in medicine.
So does anyone ever feel like this? Raise your hand if you feel freaked out, overwhelmed, paperwork, all these rules. This is not burnout by the way. This is abuse. (clapping and cheering)
And feeling the love in your heart for God while getting in a yoga position is not going to help you. Yoga will not help human rights violations and abuse. Yoga does not help prisoners of war. Yoga hasn’t helped people out of concentration camps, refugee camps. There are people suffering from human rights violations all around the world. And while meditation could I guess get you in a better state of mind before and during abuse, I just think it’s totally misdirected and I guess you do too because you were clapping. So we’re on the same page.
So I’m just going to lay it to you. Physician burnout it’s a smokescreen. It’s a coverup and it’s a coverup for human rights violations against our healers on this planet. And I’m going to just go through the details so you know a few of the categories of human rights violation because people just have trouble thinking of doctors in white starched coat walking around as suffering from human rights violations.
So let me just break it down for you. There’s a term called karoshi. Who’s familiar with karoshi? Have you heard of that term? It’s Japanese. Means death by overwork. This is actually a condition. Families can sue the employer financially liable for killing their own employees by overworking them (when they die of heart attacks, strokes and they’re found dead like by their computer because they’ve been working for so long).
Do you know the cutoff for the number of hours per week that will get your employer fined if you die from overwork is—60 hours? Just 60 hours is the death by overwork limit in Japan/Asia. ACGME thinks it’s fine for residents to work 80 hours a week! And that as an honor-system cap that nobody follows for the most part unless you have a really good residency director that likes to follow the rules. Residents in the USA right now may be working 100 hours a week, 120 hours a week. I know because I’m on the phone with them and they tell me what’s going on and I even know people that are working like seven days on, seven days off as hospitalists. So that’s like 168 hours straight. That is a death-by-overwork situation. As a result of working 168 hours per week (which is actually the number of hours in a week!) you’re probably sleep deprived. And sleep deprivation is really dangerous.
Three examples that I’ve heard recently. A physician actually ended up in status epilepticus, like in the ICU with event like almost dead from seizures as a result of sleep deprivation and overwork. Well, luckily she came out of this alive, went to a follow-up appointment with a neurologist who basically said, “Oh you’re a resident, we see this all the time in the residents.” So that’s normal, that’s okay to lose a few—collateral damage from seizures.
Then I was speaking with a woman who is six months into her psychiatry intern year. Cush compared to surgery. Right? She tells me in the first six months of her psychiatry residency she only saw her infant daughter for six waking hours of her life. Does that piss you off? Because it pisses me off. And this is not only causing a problem for her with sleep deprivation, it’s maternal deprivation on the child. I think we’ve already done those experiments and they’re not good. This is going to cause problems for the next generation. When you treat workers like this. These human rights violations are perpetuated in first-world brand-name hospitals.
One doctor was so sleep deprived in residency, he actually fell asleep while trying to start an IV on a comatose patient and they found him like in bed with the comatose lady. Like this is how sleepy people are. This can’t be good for you.
And then there’s bullying on top of that. They’re telling you you’re an idiot, you’re too slow, they’re writing you up as unprofessional because you said that maybe you need to sleep or something like that. They’re throwing scalpels at you in the OR.
Sexual harassment. I hear about this all the time. I mean you guys might not know so much about it as it’s mostly women who call to tell me some such things as “they’re groping me” and “the guy in the OR who’s my attending is walking by me and rubbing against my breasts.” If she complains (this universally happens, by the way) she is written up for unprofessional behavior. They blame the medical student. Tell her she is a difficult student and then preserve the career of the guy who’s the surgeon bringing in the money. Throw the woman friggin right under the bus. Is that what you want going on in our profession? This is happening. This needs to be dealt with. Sexual harassment is a human rights violation.
And then one of my favorite—food and water restriction. I’m really into fasting but fasting is contraindicated if you’re diabetic and a number of other conditions I saw on the slide (in an earlier talk). Add residency up there too. This is not a good time to be on an intermittent fast for like seven years. Sleep-deprived hypoglycemic doctors are wandering around hospitals trying to steal apple juice and crackers from their patients or from the nurses station. They’re in terrible shape. The water restriction before prolonged surgeries, they’re withholding water so they’re not having to leave the surgery during the 10 hour case. As a result, doctors are getting kidney stones, having all sorts of dehydration issues—collapsing during surgeries.
Here’s an example of what happened when I was a third-year medical student during a C-section. I’m sure I wasn’t doing anything too important other than standing there with another third-year medical student. Then she collapsed onto the floor and they came in and took her blood sugar (she happened to be a little overweight and on Slim Fast, bad idea to be on Slim Fast during medical school I think). But anyway her blood sugar was 26. She was out. Now I was hyper as can be. For me, fasting is a lifestyle I think because my parents are both physicians and didn’t have time to feed me. I’m not kidding like my first family picture with my parents was when I was 45. They’re super workaholics. I mean seriously like I’m an expert at physician psychology. So anyway I was just like, “Hey, while you’re here since I’m spazzing out and bouncing off the walls like I wonder what my blood sugar is?” They took it and it was 24.
I made it through medical school on organic carrots, kale and lentil soup. I never used any caffeine. I was like super pure then. Isn’t that amazing? But I made it through with a blood sugar of 24. I don’t know, that doesn’t seem healthy either.
I was vegan for 22 years which was very healthy for me. I just thought I’d throw this in because it’s kind of an interesting story. So I didn’t even own a refrigerator for 10 of those years because I grew all my food in my yard. So I was like super-hard core vegan. Now I’m vegetarian and that was mostly because I had a foster child that moved in and I didn’t want to have food fights with him because I knew we were going to have other drama.
Racism is also a human rights violation. Particularly bad, the darker your skin and if you’re J1 visa and you’re female. There are clusters of J1 visa female suicides at some of our finest first-world medical institutions.
I want you to look at this list—actual human rights violations that are happening every day in our medical institutions to our brothers and sisters in medicine. Certainly the combination of these could cause karojishi which is an actual Japanese term that means suicide by overwork. That’s why physicians have the highest suicide rate of any profession.
We should be completely ashamed that this is going on in our hospitals. Covered up by the AMA. I was supposed to speak at the AMA at one point and they retracted the speaking engagement because they were “uncomfortable with physician suicide.” We’ve known that doctors have a high suicide rate since 1858 in the UK when it was first reported. So I’m just bulldozing ahead because it doesn’t seem like there’s many other people that are interested in taking it on and I’m tired of watching everyone die. I’ve lost both the men that I dated in medical school to suicide. Not while I was dating them. When they married other women. Left those women and their children behind.
I was suicidal myself as a physician and I survived that in 2004. So I live to tell the story of suicidal physicians—channeling the messages of those that we’ve lost by suicide. Three men in my town died by suicide in just over a year and I live in a small beautiful town where everyone holds hands and sings Kumbaya and goes to Farmers Markets together. In Eugene, Oregon. Top-rated doctors. The prime of their careers. So I wonder how many doctors are dying by suicide in Chicago? Philadelphia? New York City? Doctor suicide is a huge underreported problem.
So here’s my story. Basically I did everything right. Had a 4.0 GPA. I followed all the rules. I worked insane hours. I had no personal life. I did everything right. And I did this so I could help and heal others. As a result my life totally sucked. I was in a big-box clinic. See that little drawing of somebody saying help, trying to jump out. That’s me! Trying to get out. See two rows down from the top.
Yeah my life totally sucked because I was double booked. We didn’t learn about that in residency. That’s where they stick two people in the same slot for a 15-minute appointment which makes it a seven-and-a-half minute appointment. So seven-minute visits, unhappy staff, everyone’s exhausted. There were embezzlers in the clinic. You can’t really keep track of embezzlers rushing through seven-minute visits. So that’s a good time for someone to come in and steal all your money. Fraud and theft and depression. I felt like a lot of doctors feel—they feel like they’re locked into criminal rings committing insurance fraud just to stay afloat. Just being honest here.
Assembly-line medicine made me suicidal. My suicidal thoughts were 100 % occupationally induced. A lot of the 1100 doctor suicides I’ve researched are largely related to professional stress. And by the way, if they have personal issues the origin is probably professional stress because if you work 120 hours a week is your wife or husband going to be really happy with you? Probably not. Are you gonna be a good parent? No. So if you’re having problems at home it still tracks back to your career. Assembly-line medicine is absolutely dangerous. It’s dangerous and unsustainable; emotionally, physically, spiritually, financially for the patients—and for us.
And we need to just jump out of this as soon as possible so I commend you all. How many of you have jumped out and started your own practice? Woohoo!! You are part of the solution. Thank you.
Just to be clear again, meditation, yoga poses, and swing dancing is not the answer. Reason why swing dancing is on there is because I was at an AMSA convention and a wellness speaker actually suggested that the doctors and residents and medical students take up swing dancing to help their “burnout.” Like is that total crap? I mean how lost do you have to be to suggest swing dancing as the answer to human rights violations and overwork leading to suicide?
So how did this happen to us? Well, we had an inadequate medical education. I think you all probably agree because you’re here getting continuing medical education in things that you wish you would have learned in school. And you’re paying extra because your medical education lacked what you wished you would have received.
In medical school we basically learned the technical skills of patriarchal reductionist Western medicine. And we’ve got a ton of loans right we’re still paying off too. But we don’t learn any human skills. We don’t learn any business skills—a problem you might notice if you try to launch a practice or try to actually be a doctor. If you don’t have the human and business skills it sort of undermines your ability to even practice medicine properly with only technical skills (in seven-minute visits!)
So they teach you the technical skills and then they do this really interesting thing where they act like you have a lot of choices, like there’s so many options. Like what specialty do you want to pursue? Well, you could do treadmill OB. That sounds like fun.
You could do rat-race pediatrics, seven-minute visits with kids shoving needles in them.
You could do drive-by psychiatry. That’s really fun. That really helps. Yeah. Has anyone noticed that we have sort of a global mental health problem in the world right now? Well, drive-by psychiatry is not helping.
You could do assembly-line urology. That’s fun.
I like the next slide because look at his finger. There’s a better way. I have the solution.
I want you to understand if you’re feeling personally bad about where you are in life right now in your career I want you to know we were set up to fail. It’s not your fault. It’s not your fault if you’re not where you want to be right now with your income, with your love of the medicine. Not your fault. You were set up because medical education in its current form is an anti-mentorship program. You meet a lot of doctors you would never want to become. Is that true?
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So as a result of losing our mentors in an apprenticeship profession we’re kind of just winging it—lost, like we’re sort of just out to sea. And so I want to help you. That’s why I’m here. That’s why they brought me. I think we need examples of people (like those of you who are insanely blissed, real doctors who’ve sort of figured it out and can lead the way like a sherpa up the mountain with a flashlight. People who know how to do it. I want to help you and here’s the challenge I have for you.
In less than 30 days you could be as blissed out as all the people that raised their hands in the room. You could have your dream … and some of you are looking at me like I’m insane but you could actually do this in less than 30 days. It’s not that hard. You could have your dream clinic. (FYI: if you want one-on-one help to launch happy to help you here).
I’m going to share my personal example of how I launched my clinic for $627. I launched my clinic. I’m making more than I made at my assembly-line job and it only cost a few hundred dollars.
And by the way—accidentally with no intention of earning more because I’m not even a money-driven person, I accidentally tripled my income. And I did this without turning anyone away for lack of money, in 13 years I’ve seen everyone who wants to see me as long as I have space in my clinic. And I make it work.
I did this by doing the right thing. This is not about two-tiered health care. Just taking care of the worried well or doing little gimmicks on the side to get people in and all this stuff that people do to try to generate money with ancillary services. I’m just actually providing really good primary health care. This is me doing house calls for the homeless on a street corner in my town which is not a big money maker but hey I have a lot of time on my hands now that I’m tripling my income, I can go hang out on a street corner under like overpasses and help people and hang out and talk and eat lunch with the homeless and do whatever I want. Which is awesome.
The coolest thing about it is when you’re self-employed you get to be a real doctor. Who wants to be like a real healer? Like reach your soul’s potential on this planet. And these are just little clips from news articles and shows because people find it really interesting when they meet a real happy doctor.
So my goal today is to share the wisdom that I have from 25 years as a doctor and 13 years in private practice in an ideal clinic. To give you the shortcut to your success. Help you reclaim your power as a healer. And get you back to being a real doctor and not an assembly-line worker. We’ve just got to stop with these big-box clinics, with this assembly-line medicine. This is not the way to practice, it’s dangerous for everyone.
And I have three secrets I’m going to share and I’ll go through each one separately.
Secret number one is how to launch your dream clinic in 30 days for less than $3000. You might be able to do it even for a few hundred. The reason why I’m sharing this is I don’t want anything to hold you back. Some people are like “Oh, I need a bank loan” or “I need a big building.” You don’t need anything, you could start right out of the gate. People are desperate. They need doctors. If you haven’t noticed the bar on customer service sucks in health care. All you really have to do is smile and be on time and have like two chairs and people will come and pay you cash. I mean really the need is huge. Then I’ll share secret number two—how to earn more seeing fewer patients and longer visits with no staff or interruptions. And number three—how to fill your practice quickly without spending any money on advertising.
So the first one, how to launch your dream clinic in 30 days for less than $3000. And those of you who already have your clinic launched, explore what I’m sharing now as an opportunity to redesign your current practice if you’re not blissed out. If you’re not currently blissed out and you are self-employed there’s still room for improvement and you still have a little ways to go to get to your dream clinic.
I assume most of you in here are not super specialized doing lung transplants and needing a helipad and tertiary-care hospital. Most of us are doing outpatient medicine. We’re cognitive specialists, not proceduralists by and large. If you’re a cognitive specialist that means all the important stuff is in your head which you paid $300,0000 in student loans to get. So that means you could pretty much run an office right here in these two chairs. You don’t really need anything else because you’re already smart. And what you don’t know, you can look up.
So what do you really need to start a clinic? Like if you really had to, if somebody basically said you had to start tomorrow and you didn’t have a choice and you had to do it. You would go to Goodwill or you’d pull two chairs out of your house. You’d bring people over your house or rent a space. You’d get a piece of paper, a pen and your stethoscope and if you’re a psychiatrist you could throw that out and you would be all set. I’m just breaking it down. I think we make this way too complex and the reason why it’s complex is you’ve got a lot of people making a nice passive income off your heart, soul and intellect and they don’t want you to understand that you could make triple the income with two chairs and a piece of paper. They don’t want you understand that. I’m just telling you the truth. Let’s get real.
Because the bottom line is all your patients really want—this is the secret sauce—this is the what’s been missing for those of you who are struggling trying to figure out what accessory things you’re going to add to your practice and how you’re going to do little gimmicks here and there, I want you to know the secret sauce is . . . YOU.
That’s what they want. They just want you. So you don’t need to do a lot of fluffy stuff here, there and everywhere. Just be the original healer that you felt called to be on this planet and people will line up in droves. I’m not kidding. This happens over and over again.
There are only a few ways where folks fail in launching their own clinic. If you have PTSD and you’re currently suicidal, it’s a bad time to open a wellness center because you need help yourself. I mean there are people who basically took all my advice but I didn’t understand how their untreated mental health issues could undermine their own clinic. So they’re wondering why no patients are coming. Well, you’re sort of not attracting patients when you’re sick. You have to be well yourself. Put on your oxygen mask first then help your child sort of thing.
What else undermines people? Sometimes they’re just like in the completely wrong area. If you want to help menopausal women but you’re working you’re near the Alaska oil rigs and there’s only men there. You know what I mean? So choose a proper place. There’s just a few simple things. Get some help with a mentor—like the people that raised their hands blissed out could probably help you. I’m happy to help you. My best advice no matter how big and fancy you ultimately want to get you should really start out with no staff.
Do everything yourself because it’s really fun! You get your own insurance checks. This physician was so excited she said, “Oh my God. I just got my first insurance check, this is actually working. My name’s on the check.” And I was like “Right. Yeah. That’s how it works. Yeah. Right.” Before, somebody else was getting her check—the revenue she was generating—and taking 70 percent!!! Just giving you scraps and writing you up as unprofessional.
Administrators know how to intimidate doctors and keep you in fear of losing the job that sucks. They would not want to empower you because you are their greatest competition. You can go across the street and earn three times as much. They don’t want you to know that.
Back to staffing—you can always hire people later but start with no staff because it’s really good to know how to do every little part. Now for me in my case I am solo-solo which means I have no staff. I do everything myself. I submit my own claims through an online clearinghouse. I schedule my patients. I currently have about, well I only work two half days a week now but most of the time for the last 13 years I’ve worked three half days a week; Monday, Wednesday, Friday, because I’m totally against working two days in a row. I just think that’s too taxing. It’s too much. I mean really you’re supposed to live your life too, right? Aren’t you supposed to have fun sometime? You don’t want to be one of those people that retires and you’re like what was this all about.
The other thing for me is I haven’t set an alarm clock for work in 13 years! I’m not a morning person. I like to stay up till 3:00 in the morning and then go to sleep, wake up around noon like when my body tells me. I don’t want to hear loud noises that force you out of bed. That’s the worst thing ever. So I think one of the joys of having your own practice is you can set it up so it’s in alignment with your circadian rhythm. Patients really love that too because I work afternoons and evenings like 3:00 to 7:00. I’ll stay as long as the patients need but the deal is like people love that they can come after work or that you do house calls—and that you’re in a good mood. You know what I mean? People will pay good money for their doctor to be in a good mood. That in and of itself is rare these days.
Now think about how much space you really need. And some people end up in high-rent medical space by the hospital. You don’t need 2000 square feet. I’m in an office that’s 280 square feet. I mean how much space do you need for your brain and two chairs? Not much. Right?
Like anything else you’re paying for, you’re paying for all the extra square footage that’s around your chair. I would just get these two little blocks here and sit. As long as you can sit and get people in the door. You could do it in a broom closet. And actually I want to tell you about a nurse practitioner who did start in a broom closet because her clinic wasn’t ready yet. She was having all sorts of fancy stuff done. She’s in Alaska. The hospital actually gave her a free broom closet to set up in because they really were desperate. Alaska by the way has really high reimbursement, highest in the country, if you want to make a lot of money just go to Alaska for a short time, you can really make like probably about ten times as much as you would make if you lived in Ohio for the same work. Very interesting story behind that.
But this nurse practitioner she actually is making close to a million dollars a year and she started doing that just out of a broom closet generating that much income because you can bill a 99215 in a broom closet. It works. Insurance pays that. Patients will pay you cash too. Even in a broom closet!
So I’m going to share some of the actual rent that I know that doctors are paying. I know doctors who’ve gotten free space, completely free, because people are so excited they’re opening a clinic in an area that’s under-supplied with physicians. They’re like “Take this space for free, we love you.” That’s awesome. That’s available for you too if you’re not in a saturated area. And by the way even if you’re in a physician saturated area I bet it’s saturated with assembly-line medicine big-box clinics and it’s not saturated with real doctors like you. So don’t be deterred even if there’s like a doctor on every corner. But they’re probably like unhappy, even suicidal doctors. If you’re the happy one in your own clinic you can still do really well for yourself. I know somebody that got her clinic building for a dollar per year. I mean they had to somehow charge her something so this town in Westerlo, New York made her a special deal, a dollar/year. It’s pretty good. Main Street location.
I know people that had their whole first year of rent waived. I know people who got like a philanthropist to give a $100,000 loan to start even though she didn’t really need that much money but that’s pretty nice. When I started my clinic 13 years ago I paid $280 a month for 280 square feet and now it’s gone up over 13 years to like 425. Recently a physician got a really cool space in a skilled nursing facility, I think she rented like an empty room for $118 a month which is great.
So look around. Be creative. Even in high-rent districts like Brooklyn, New York and Chicago I know physicians getting awesome deals, $600 a month rent on their offices. So I’m just throwing this out here because I want you not to be deterred by price. You can start right away. And just make it like a fun contest like how low can you go and still be a real doctor. That’s what I wanted to know, like how scrappy could I get. How frugal could I get and still be taken seriously on planet Earth. And you can go pretty low. I got my overhead down to seven percent. Before that it was 74 percent.
So here’s my launch. The actual numbers to start my practice and start collecting money. I got chairs from Goodwill for $40, wicker chairs, I’m still using one of them, 13 years later it’s holding up. Why get a new one? Office rent $280. And then malpractice which is billed quarterly so for my first year I paid $307.50. So for $627 I had a medical clinic in the United States and was getting money rolling in without doing Botox, without doing special weight loss stuff. I mean you can do that if you’re really into it but I just was being a real doctor treating strep throat, UTI, Pap smears, pneumonia, like all the regular stuff that people are running away from because they want to do these little niche practices but people really need all around good care and if you want to be like a family doc people will love and adore you. You’ll be the town hero for $627. And by the way, here’s How to save 86 percent of your malpractice insurance.
Here are some examples of people who started clinics recently. Janice Hudson started a clinic for $630 and she breaks it down. $280 was rent. Rent was $350. She had a down payment on malpractice $280 but see most of us already own a stethoscope and we already own a computer like you don’t have to like recreate the wheel. You can add stuff as you go along.
Kayla, this woman is amazing. She started a clinic for $85. How do you start a clinic for $85? Look she moved to a new town and launched 48 hours later. She’s like super nomadic and adventurous. She spent $85 on a bookshelf. When she launched her clinic she actually hadn’t paid any rent yet because they hadn’t collected it. So she made $330 her first day and paid rent later. Is that cool or what? Is that amazing? Do you guys love that? Who wants to do that? Isn’t it fun?
All right. So I want you to be aware of procrastination tactics. Doctors are so perfectionistic. We don’t want to start until we have a logo. Who cares? Nobody cares. People are dying and you’re waiting for a logo. Don’t. You don’t need a logo. I’ve never had a logo. I never even understood what branding and logo was. Its like isn’t that me, like can I just be me, do I have to have a brand and a color, that seems too marketey, like just “I’m here. Hi. I’m open.”
Website. You don’t need a website. I personally have one because I have a blog. If I didn’t have a blog I probably wouldn’t even … you don’t need a website. Everyone thinks, “Oh, can’t start my clinic until I have my logo, I have to figure out my colors, my website, letterhead.” I don’t have letterhead.
Office space. If you can’t find office space just start doing house calls. It’s so funny some doctors who I’d helped with this they’re like, “Well my office isn’t set up yet so I told her ‘Well it’s not set up so maybe I can come to your house.'” Don’t apologize. Don’t explain it like that! Say I’m having a special. I’m going to come to your house and do a house call because you’re special and they’ll be so impressed they’ll pay you extra. This one doctor because her office wasn’t ready, she had to go to the patient’s house and she tells me, “Well I decided not to charge her because I wasn’t ready.” Not charge her? Are you kidding? Charge her twice as much. You came to her house.” The woman was there with cash and was throwing at her and she’s like “No, no, no, no. I’m a perfectionist and my office isn’t ready yet. So I’m a loser so I don’t deserve any money.” Oh my God, this is distorted thinking patterns of perfectionist abused people.
All right. Your EMR. I have a do-it-yourself EMR created on my laptop, I didn’t pay any money for it. I’ve had it for 13 years. It works great. You can still use paper, who cares. Get out a pen. People are dying waiting for your logo. Don’t hold them up. Okay. People I’m serious. They have cash ready to throw at you but you’re wondering how to write the perfect office policies. Who cares. Just open the door and let them in.
Staff. You don’t need staff. If you get so popular … One woman contacted me yesterday. She’s like “Oh my gosh. I’m open six months now and now I have a waiting list and maybe I should hire more people and open a satellite.” I’m like “Do you really want to like complicate your life? Just stop right now. Take care of the people that you have. Unless you want to be like some famous doctor with 13 sites in 12 states just stop and enjoy the patients that you have or you’ll drive yourself nuts. Mentor other residents who rotate through your office.” That’s what I did. I had a waiting list after six months but I kept it just so I could give it to the next doctor and help her launch her practice. I can’t take care of everyone.
And Band-Aids and supplies. A psychiatrist, oh is so funny, she needed Band-Aids because I guess there’s an injectable psych med that she does only four times a year on one patient. And so what did she do? She ran to Walgreens and got a Band-Aid. BFD. You can do that. You don’t have to have all the stuff with you on day one. Oh you don’t have a sink in your office. This woman calls me, she goes “Thank you. That was such a great idea. I got a portable sink. I’m all set. Great, get a portable sink. Open in a boat. It doesn’t matter. Just get going.
I’ve never had a bookkeeper. What I do is I take my taxes on vacation with me and I take them out to dinner and I get room service and I have fun with all my receipts once a year. It’s like a party. I really recommend when you do stuff that you otherwise hate like balance a checkbook just take it out to dinner. I got divorced. I took all my divorce paperwork out to dinner, I got non-alcoholic drinks all night long going through it (I’m a lightweight and can’t drink alcohol). Stuff that’s not fun don’t do it alone moping at home, go out to a fancy restaurant and tell the waiter, they’ll be cracking up that you’re there.
I’ve never had a CPA until recently. But for most of the time I did my own taxes. This is really easy. Schedule C by the way stands for creativity. You can get really creative. Write everything off.
Attorney. I never had an attorney except for my divorce. And computer, I already owned a computer. You don’t need a phone system I’m sure everyone already has a cell phone so just get going.
Sharps container, look I am still using the same sharps container I got 13 years ago and I do skin procedures. That’s because I’m very frugal. I only take off the needle I throw the other part in the trash can so it only has the needles. It takes a long time for needles to stack up and fill up even the smallest sharps container. Seriously you don’t have to spend a lot on that. And that psychiatrist I know who does the four injections a year she cracks me up like you wouldn’t believe. She doesn’t have a sharps container because she only has four needles a year. She takes it to the casino. Everyone’s dropping theirs in casino bathrooms in Oklahoma. There’s like those little sharps containers, she just takes it down there to the casino every time she has to throw out some. So you can be really frugal. I think we’ve overcomplicated the delivery of medical care. Would you guys agree with me? Geez.
Exam table. Just have them get up on their bed. Like whatever, it doesn’t matter. Use a massage table, rent an office one day a week from a masseuse and use their massage table. No board certification? No problem. I gave mine up and I’ve never been happier. You can do it too.
Others drop needles in the casino, have no website, or forms with headers, and no logo. Just jump in. Make money. All cash. My friend Keely won’t even take credit cards (I don’t either) because her husband’s cheap and doesn’t want to pay 3 percent to the bank. So she’s all cash and a child and adolescent psychiatrist in Tulsa and she should be a stand-up comedian. She is a crack up.
And Kayla there’s her bookcase that she spent $85 on to start a clinic. Everyone could do that. You don’t have to be special. You can go to a second-hand furniture store and get one.
The most popular way of procrastinating is continuing to consider other job options that are obviously not right for you. Don’t do that.
So secret number two, how to earn more seeing fewer patients and longer visits with no staff or interruptions. Look this is an example. You see a patient for 20 minutes and diagnose bronchitis, the patient pays you $100. How much do you think you got to keep when you’re an employed physician, an employee?
Well, look this is my true story. They gave me $26. My overhead was 74 percent.
That does not seem like a good deal because right now I keep $90 because my overhead’s about 10 percent.
So if you think about these numbers here’s a quick math problem. So $90 divided by $26 equals you just earned 3.5 times as much per patient. Who wants to earn triple your income per patient? Raise your hand. Would you like to earn three times as much? Just be self-employed. You can triple your income.
The secret to secret number two is actually having low overhead. When you have low overhead you keep the money that you earn. See when I was paying 74% overhead that’s as bad as moving to a state with 74% income tax. Would anyone do that? Would anyone move to a state with 74% income tax? You just took a job that’s the same thing. That makes no sense and people are doing this because they’re afraid they’re not smart enough to open a clinic but most of the people that work in a clinic just have GEDs or low-level education and are doing the same repetitive tasks. They would never be able understand the Krebs cycle which you understand and all this other stuff. So trust me, you have the IQ to open a clinic. It’s not that hard.
And here’s how to fill your practice quickly without spending money on advertising. This is a cool thing that I did. I was so suicidal I could not function. I had this idea that like if I couldn’t figure this out maybe somebody would help me in my town since everyone holds hand and sings Kumbaya. I just threw a little town hall meeting while I was just sort of coming out of my suicidal stupor and I said, “Hey I’m not happy as a doctor, you guys might not be so happy as patients, why don’t we just start over? Let’s design an ideal clinic and see if it works.” And people submitted 100 pages of written testimony. I pretty much told people I’ll do whatever you want as long as it’s basically legal. And I was able to do 90% of what my community wanted and open one month later with no outside funding. Is that great or what? You could do that too.
It’s so funny. People ask, “How do I start my town hall meeting? Where do I go to the city or the mayor? I was like, “You don’t ask anyone, just throw a town hall meeting and get going.” I didn’t get permission. Should I wait for Obama or Trump to come to town and lead a town hall meeting to find out what people want for healthcare in Eugene, Oregon or should I do it? It totally makes sense that I would do it because I already live there and I already love everyone in my town. So you probably like where you’re living so just do the same thing.
This is actual testimony—what people submitted at my town hall meeting. They wanted a doctor that’s self-employed or works in a small clinic doctor owned. Somebody wrote, “I’d like to see a relatively relaxed physician in a calm space, someone who has plenty of time off.” Would you like that job? Anyone? Interactive low overhead, kept small and personal and one gal asked, “What equipment is really necessary?” What is really necessary? Nothing. Just your brain.
So one happy patient can actually fill your practice. I was totally confused one day when I had like 5 people from the Relief Nursery calling for an appointment. It’s because I saw one person from that Relief Nursery as a patient and they went and told everyone in the lunch break room about what an awesome doctor they saw and then everyone called for an appointment. I mean one happy patient is like a little megaphone running around town telling everyone else and they’ll fill your practice. You do not have to take out newspaper ads, put billboards on buses, you don’t have to do anything like that.
And in case you’re not aware, the Titanic is sinking. Big-box medicine is failing. I think that’s why you’re here at this conference. You’re making your plans. You’re ready to get in your life raft.
I’d suggest that you jump in as soon as you can and start your own clinic. You could do it within 30 days. I’ll help you. There should be nothing holding you back. I think I’m making this very clear. Very easy. I could teach a 4th grader to launch a clinic. They couldn’t deliver medical care, but they could totally learn to run the clinic. It’s not hard but somehow people with all this education think it’s too hard.
So you could be in your ideal clinic. I suggest you don’t wait until your emergency. What is your emergency? Well, I run a suicide hotline so I hear from a lot of doctors with PTSD. I hear from people who are suicidal in the ICU. They just were on a ventilator and they’re calling for help. Please ask for help before you’re on a ventilator after your suicide attempt. Get help before. I know physicians are so resistant to asking for help but please, please, please do it before your divorce, before your financial ruin, before your malpractice case and before you’re locked in a psych unit.
And by the way just a reminder, you don’t need an MBA, an MPH, you don’t need any more board certifications, you don’t even need to complete your residency, you can do this after just your intern year. You don’t need a second residency. I met a guy who had five residencies like when are you going to start seeing patients? Who knows. He’s still reading the books. You don’t need any special certificates. You don’t need to ask permission. You’re already adults. Isn’t that cool? You don’t have to ask permission. I’m giving you permission today to do it. You are smart enough now to do this.
Here are some examples of blissed out doctors. . . .
And then I have so many ideal clinics that I’ve helped docs open. I tried to keep a map on my website but I can’t keep track of them all because everyone’s doing it, it’s really fun.
Surprise! A few more slides, your loans can be forgiven if you open a non-profit. You don’t have to work at an FQHC or anywhere else to get your loans forgiven. Make your clinic non-profit and after ten years, eight years, I forget what it is, your loans will be completely forgiven from medical school. How about that? Is that cool?
And just three more slides. I want to introduce you to Kayla. She’s the one that started with an $85 bookcase. She does sort of a DPC-type practice and she’s super cool and she basically bills people on the new moon every month. She has her whole thing set up, it’s all moon cycle medicine. She’s super organic makes like dinner for her patients every Friday night and they all hold hands and she’s looking real happy. By the way in residency she became psychotic from sleep deprivation and was forced into a Physician Health Program. This is ridiculous. These people who have so much potential are having their souls slaughtered right in front of us. I’m so glad Kayla came back to life and is launching clinics in all different states now. We love her. (so much clapping for Kayla!)
Meet Leslie McPherson. She wanted to be a family doc in her small town in North Carolina because there’s no doctors there. She literally had to go to school in the Caribbean, leave her kids to be raised by her parents temporarily. Finally made it back, I gave her a $10,000 scholarship which I do once a year for somebody who really inspires me and makes me cry (happy tears) and I just loved her commitment so much that I gave her the money. She got a down payment on that farmhouse taken care of and now she rents the top as an Air BnB and runs a clinic to serve all the poor people in her small town. Is that awesome? She’s like a total hero. Let’s hear it for Leslie. (clapping)
Finally here’s Keely Wheeler who dumps her sharps container shit in a casino. She is so funny but the thing about Keely that’s awesome, so many things about Keely are awesome, but Keely after two years in her practice lost 125 pounds, ends up running marathons. And people ask her all the time because before she was eating Whataburgers that her husband had to sneak her under a bullet proof glass window at a stupid psych clinic that she worked before where the administrator said, “You’ll never succeed on your own.” But as soon as she opened they sent their own kids to her because they know how sucky their own care is at their clinic. Of course their kids need psych care because their asses. And so anyway Keely I just want you to know like people go up to her and they ask her what diet she’s on because look how healthy and happy. She has candlelight dinner in her office. You know what she says, “I’m on the I love my job diet.” That’s what she says. (Clapping)
So I want you all to be on the “I love my job” diet. I want you to have the best sex you’ve ever had. I want you to be in love with your husband and wife. I want you to have the most amazing life ever. Thank you very much. (Want to launch your ideal clinic? Here’s how.)
Thank you for that powerful address. It is not an easy topic Pamela, but we are all the better for your bravery to speak on it.
Do you have anyone making this work in pediatrics?
Definitely works in peds. Any outpatient-based specialty (without HUGE capital expense)
But how do you make this work with vaccines? Insurance pays crap on vaccines (like cost if you are lucky) and it’s 1/3 of operating expenses. You can’t do peds without vaccines–it’s not fair to send patients to the health dept for vaccines. Basically, I’m asking is there a pediatric practice out there following your methods that is doing well and doing vaccines? I’m tired of seeing 25+ patients a day to pay an army of support staff but I don’t see how doing this all myself will work.
I’ll reach out to one of my favorite pediatricians and ask her to respond. Great question Greg.
I am 5 months in to my ideal pediatrics clinic. Vaccines are very expensive but I also am part of a vaccine buying group to get discounts. I keep very low inventory. I only purchase what I need for upcoming appointments. Delivery is usually within 48 hours so it has worked so far. Enrolling my clinic in VFC (Vaccines for Children) was a MUST for medicaid/uninsured kids. I have no staff yet. I give my own shots which has actually been great to my surprise. We gave vaccines in residency but never in practice. It is just so nice to use my other skill sets. (I can do more than type in an EMR!!) I am still learning so much in my new business but the vaccines have been covered pretty well so far.
Oh super smart that you order just what you need. My first order of supplies lasted nearly two years so I think there is a tendency to order too much and pay the price. Awesome Kelly!
Peds is by far the lowest paying field out there. How are they making this work in peds, especially with underpayment by insurers not just on office visits but also vaccines, which are about 30% of overhead for a pediatric practice. As appealing as I see your model, I can’t see how to make it work in peds short of not doing vaccines which is a no-go for real pediatrics.
Some are not handling certain vaccines in their offices. Anything that is 30% overhead should be reconsidered. Still I do know many peds practicing independently in successful modes.
You have to make sure you get your vaccines directly from manufacturer… for best rate, and be part of purchasing group to get further discount. Then insurance definitely covers cost. And you have to make sure it’s billed correctly… meaning that your biller is appropriately charging just above the cost of the vaccine plus the admin fee for each vaccine given. The insurances are paying the base cost of vaccines. But not the cost of staff accepting/cataloging and electricity/refrigeration… that’s why you have to charge more than your cost for just vaccine to insurances. When you get them from a 3rd party not directly from manufacturer your cost/price can be jacked up 3-10%. Gardisil 1987.. from manufacturer.. but like 2210 from a 3rd party that’s when you loose money. Most peds do a little better than breaking even on vaccines… it should not be a loss to your practice or you are not doing it right. But you have to keep up with what insurance is paying you and your cost. For a period of time the retired doc didn’t give gardicil cause insurance wasn’t paying the cost. Once insurance caught up with cost then they offered it again.
Thank you Paula!!!! Excellent advice.
I also agree and do things similar to Kelly (except I do have a larger staff and practice, 1FTE for front Desk, 1FTE for RN/MA, and one NP). We review our small vaccine inventory daily and only order amount needed every 2 weeks period. On average now, I have about 5-10 doses of each type of vaccine, once the stock of one vaccine gets down to 2-3. I will order more and how much more depends on the season and what needs I will have in the next 2 weeks. And my ideal medicine Pediatric practice is working great!!!
what would be your reccomendations for a first year nurse practitioner student, in preparing for being a happy nurse practitioner. what kind of things should i not fall prey to in the academic world? what would you do differently. i have a little business experience in setting up and running my own (with my wife) assisted living home (10 beds) and have created most of the forms that the state requires etc. i am a little burned out because this ties us down 24/7/365. i like the idea of a DPC but the area i live in is a retirement community in NW Arizona and most of the retirees have little retirement savings. there is also a lot of drug traffic in the area as whole neighborhoods of “trailer trash” folks can attest to. i am a little concerned about not taking insurance, medicare, medicaid etc. might not work here. any thoughts would be welcome. Thanks Dr. Wible for giving us hope that it can be done.
Ask people what they want. What is the unmet need that you can fulfill as a nurse practitioner. Get to know your community. Happy to help you.
Your work is truly amazing Pamela. You are clearly saving the lives not only of your patients, but of the many defeated physicians as well.
Kudos and GOD bless!
I am ‘just’ a MSN but I am looking at starting a home care company. I have a business background but need help learning how to become a Medicaid provider and have that ability to bill Medicaid. I love your keynote-I can use my home and laptop to get started. But it is that fear of Medicaid and billing that scares me! Thanks Pamela!
Dr. Wible – I’m hoping you’re still out there!
I’m so encouraged by your story and your mission.
I am currently living in a nightmare of conventional medicine. After 15 years of school, residency and even Cardiology fellowship – i am struggling to practice because I am not board certified!! Why – because I had 3 kids during my eligibility years complicated by eclampsia and post partum medical issues.
I am thinking of taking a leap of faith and starting my own Women’s Heart Health Center – body, mind and spirit – but I’m scared because of medical school debt and the area where I live.
Any chance we can talk? I feel compelled to share my story and to change my trajectory and live my dream – while supporting women physicians and standing up for what is right!
Please contact me if you can!!
What do you do about lab and radiology? Do you contract these services?
Yes I send out as I always have.
Hi based on your method do you have an actual clinic or is this more of house calls? thanks!
You could do either.
based on your method do you have a clinic or is this more of house calls? thanks.
Yep. Happy to help you. Contact me any time here: https://www.idealmedicalcare.org/contact/
Great idea! Feels very hopeful and doable. I am a Physician Assistant and my MD partner are Covid fatigued. We work Urgent Care and we are inundated with testing and minimal urgent care patients. We would like to get back to caring for patients. We are considering opening up a small clinic that would include home care services. Cash only no insurance. Have you been hit with Covid requirements? Is your plan still doable in this Covid climate?
Yep! Absolutely. And Telemedicine better now that ever.