The Surgeon Who Left So He Could Stop Operating

Well, I did in fellowship already.

Okay, so minimum.

But so you didn't know the science of it at all.

So when you're sitting there and you were listening to the science, do you remember when the bell went off when all of a sudden you're like, oh crap? You know, when you could start seeing like the mass implication, implication, implications of it? You didn't build your clinic to feel like an employee in your own business. I'm Matthew Colobley, and on Out of the System hosted by DrTalks, we challenge the broken rules holding healthcare entrepreneurs back. Hear from clinic owners, rebels, and builders who are creating Bold, profitable, patient-centered practices and doing it their way. I'm sitting across from Dr. Marc Eisenberg with Iron Mountain. Do you call it orthopedic?

What is it? Iron Mountain Orthopedic Institute.

Okay. And where is that located?

Huntington Valley, Pennsylvania.

All right. And so tell everybody a little bit about, just a little bit more about who you are. You're relatively young to, you have your own practice. You're relatively young. One for our client base, To— well, and we'll talk about kind of your journey in a little bit, but tell everybody a little bit about what you do.

So I'm an orthopedic surgeon, subspecialty in sports medicine, minimally invasive surgery of the shoulder, knee, hip, and ankle, as well as shoulder arthroplasty. I still do a lot of trauma, relatively speaking, and always try to find a less-is-more approach for patients. And regenerative medicine fit pretty neatly into that philosophy. So it's very hard to run a regenerative medicine clinic in modern-day medicine, especially if it's owned by hospitals or private equity.

It's impossible.

It's impossible.

It's impossible. There's no way a hospital or a large group would want to do this.

No. My first group that I was part of after fellowship was a private group, and they sold to private equity eventually, which was good for them, but was not really what I envisioned.

The 6 partners sold and you were going to be number 7 and were on the outside looking in or something like that.

Well, it was, it was a, it was an expected partnership eventually, and it just kept being held up and eventually the whole thing sold. So, yeah, left that, joined a hospital and practice. And in both of those situations, for me to do even basic quality regenerative medicine following the science was hard. Like I had to— the story of the first one, the first practice was they were doing PRP, for example, but what they were providing is actually PPP, platelet-poor plasma, but calling it platelet-rich plasma, which is pretty impressive. That's what was happening. But it's not bad doctors or bad surgeons. There were actually a lot of really good surgeons. They just didn't really know the science.

They didn't know the answer.

Yeah, they were trying to do the right thing. But trying to bring in a company with the right kit to just get the right dosage at least was a whole thing. Like, I'm trying to break this mold, and it's more expensive, and why are we doing that? It was worse when I joined a hospital in practice where they said they had a kit, they had a system in place. And I said, this system's junk. It's going to produce nothing.

Right.

It's like you're spitting into the joint a little drop of blood that you get anytime you stick a knee scope into the knee, for example. And their answer was, well, there was a fellowship-trained, board-certified orthopedic surgeon before you using this system. Why is it not good enough for you? And I said, well—

Well, here we go. Here's reams of data that would tell you.

Well, so actually, no, I, I didn't go that far. I just said, well, it's because the science says it doesn't work. And they're like, well, why don't you like show us the science? And I'm like, well, that's like telling me to show you how to be an orthopedic surgeon. It's not something I could just show you in 30 seconds. Like, here is the science. I could show you the basic stuff, but none of it mattered. I mean, really, you realize most of these practices hire an orthopedic surgeon to do orthopedic surgery. That's where they make their money. And anything that's going to keep patients out of the OR is not the business model. So not, and I just wanna say not, yeah, not because they're bad people or tru— it's just, that's just not the business model. So it's not that they want to force people to surgery. I don't wanna make it sound like that's what's happening. They just, if it's not supporting their growth, then it doesn't make sense to invest in it, if that makes sense.

Yeah. They, you know, look, there's a lot more Trained surgeons to replace a joint than there is trained surgeons to do regenerative therapies, orthobiologics correctly. I mean, if you think about it, how many orthopedic surgeons, I'm sure you don't know the number, but whatever. Let's say there's 1,000 orthopedic surgeons that come out of residency every single year. Well, they're all trained. relatively consistently on how to replace a knee, how to replace a shoulder, right?

Yeah.

How to replace a hip.

I never saw a single regenerative medicine procedure in my general surgery, general orthopedic surgery training.

So it's not scalable. It's in there in a private equity's mind, which I totally understand. It's not scalable. They're getting free trained doctors that come in that are ready to go. Versus having to start from square one.

You know, I actually think it's even more subtle than that. I think that, yeah, I don't think private equity has any idea of what regenerative medicine is and why they should even be interested in it. Just like I don't think most orthopedic surgeons coming out of residency have any idea what regenerative medicine really is and why they should be interested in it. So like that happened to me, you know, where I came outta residency, I didn't know anything about it. I, so I heard of it Yeah.

How did you hear about it? How did you hear about it? So you, and for the record, tell everybody, like, how long ago were you? How long ago did you leave residency?

2018.

2018. Okay. So, well, then for those of you watching at home, he's younger than most people that come out of this thing. So, you know.

Yeah. Well, the grays are starting to show, but—

Dude, you got a long way to go. Look, that's like—

In a couple years, I'll have gray hair.

That's like throwing a deck chair off the Queen Mary. Like, your gray is like nonexistent compared to mine.

Yeah. I'm getting the salt and pepper going.

Look, yeah. You know, you have a salt with a lot of pepper.

Okay. Every day that changes, but you got like one noggin of like kosher salt.

That's about it.

Yeah, so I'll take it. Okay, but no. So I did my fellowship here in LA. So in LA, it's a very different patient population than in Philly, in that what we'd see is people coming in saying, "Can you PRP my shoulder when it's hanging off by a thread?" And they think somehow regenerative medicine.

That's LA. Let me guess. That's LA. Yeah, that's LA. We talk more like dude. Can you like give me PRP to fix my shoulder?

Yeah, exactly.

They all sound like Crush.

Yeah, exactly.

They all sound like Crush from Finding Nemo. Noggin.

They think anything will save it.

Right.

And they don't need a surgery. I know.

Everybody's like, oh, you're in medicine, man? Hey man, peptides are really cool, aren't they? They're gonna like change the world, right? I'm like, not really. Oh man, I just love peptides. I'm like, where are you getting them? I got like a dude that gets them for me at the gym. I'm like, oh my God.

Yeah, that's all of LA.

Just, that's all of LA. Everybody's got a dude.

So that's how I got introduced to Regen was here in LA. And We'd find ourselves talking people out of it sometimes because it is the wrong answer for some people. But then more and more people were interested in it. I saw it working even though it wasn't done to the same level that like a high-level regen clinic does it. It was still orthopedic surgeons who had, who were some of the best in the world. Like I have, like the people I trained with here.

Yeah. And you trained under some like dogs, big dogs.

I still text them to sometimes to this day, way, way more often when I first came outta fellowship. Like I'd randomly send a message to someone that I trained with saying, hey, just wanted to let you know I wouldn't have fixed this shoulder if it wasn't for you. Like, so you're—

Yeah. You trained like you, you're really good at, you like take on very difficult cases for fixing shoulders, right? You—

Yeah. Shoulders wanna, but yeah, in general it's just, you know, I'm thankful to my mentors both in residency and in fellowship. And again, none of this is like, they, they were the best of, especially here in LA, the sports surgeons I trained with are, I would fly back if I needed a problem, something fixed, I would fly back.

You would come here?

I would come here. Yeah.

Yeah.

Because I've seen them in the OR and I know that they do a great job. But regen, you know, I'd see it more, but it wasn't, still wasn't the main focus, but they were way more educated.

But were they doing it like, were they doing it like, you know, like pulling out 10 cc's instead of like the 60 or 120?

They were using the less quality.

The less quality. Okay.

But they, you know, they, And not all of them, you know, some of them used one kit, some of them used the other kit. Some of them knew a lot more about it than others. So I don't want to paint like a global picture, but—

Yeah.

That's where I learned about it more. And Don Buford trained in the same fellowship where I trained. And so Steve Snyder, who's one of my mentors, who's again, like one of the fathers of shoulder arthroscopy and a lot of why I do what I do, suggested I see and go to Orthosono, which is Dr. Buford's practice.

And that's where we met, right? We met at Orthosono, didn't we? Or was it IOS?

No, no. I did that in fellowship still. So my first exposure to high-quality regenerative medicine was through that.

So what was that like? What was it like sitting in that room? Because I'm in that room every time and have been for 5 years.

Well, it was great in that it was my first real exposure to ultrasound beyond what I was being taught in fellowship, which was decent but basic, hearing about the data and hearing it from someone that's an orthopedic surgeon with the same training background as I had, so I could trust that they are not just peddling snake oil, right? Like, that's a big deal. And that's unfortunately like the bad name sometimes it comes out to be. So being exposed to that through another orthopedic surgeon with similar background and knowing, like, if you know Don Buford, you know that he is, I say he's my ethical North Star when it comes to regen.

He's beyond the ethical North Star.

'Cause I'm like, he like, I know he will never tell me something that's not—

Donnie's the best.

His honest truth, right? So, I believed that. I learned that about him. And I started— I came back and I started my practice and I said, hey, Donnie, who do you think is the best system to use? Before I fully knew all the science. And he's like, well, use this system. And that's what I would bring into my— so, I always did at least PRP to a basic quality level.

But, I want to go back a second because this is really fascinating. So you're sitting at Orthosono. It's in Vegas 2 times a year. For those of you that don't know, it's orthosono.com. It's, in my view, the best ultrasound training, diagnostic training on the planet. And Donnie spends at least half of the time talking about the science behind PRP and BMAC and adipose. He'll do live procedures and everything right there. It's a great course. It's a great course.

If anyone's interested in getting a regen—

It's awesome. We are there every year. Yeah, every year. I'm like, just give me the dates, Donnie. We'll be there. But when you're sitting in there, you had had zero exposure to PRP.

Well, I did in fellowship already.

Okay, so minimum.

But I didn't know the science of it at all.

So when you're sitting there and you were listening to the science, do you remember when the bell went off, when all of a sudden you're like, oh crap, you know, when you could start seeing like the mass implications of it, what it could do for patient quality care?

The truth is, The bell didn't go off, right?

Well, so you were just happy to be in Vegas and not, and getting sleeping 8 hours.

Yeah. No, no. What happened was, so, and, and this is part of like what I'm writing my book about right now.

Mm-hmm.

At least that's a little bit of a snippet of it. Like I learned about regenerative medicine. I learned how to do it the right way. I kept up with it after that conference all the way through, you know, starting practice pretty routinely. But what I found myself doing is offering it mostly to athletes and young people who are coming in, saying, well, I want to go back to sports sooner, or I want to have the best outcome with the surgery. And I've actually even found myself in the past talking people out of it that were good candidates, like knee arthritis. And they'd be like in their 70s. I'd be like, well, do you want to spend money on this out of pocket, or do you want to just get your knee replaced, even though 20% to 30% of knee replacement patients aren't happy?

But that's an astounding number.

Oh, yeah. I mean, compared to hip replacements, which are like 95% successful, but Yeah. Knees are not that good. And so I found myself telling people what's— I was making the decision for them. So the—

That is mis— that's one of the top 3 cardinal sins.

Yeah. And I didn't realize it though. So I would always tell my patients if they asked that I'm going to give you the same option I'd give my family. I never realized that wasn't true until I went to the Bob. Actually, I don't know if I ever told you this.

No.

I quote you to my patients to this day. I realize I never told you this, so—

Wow.

I say, what changed for me and what started my practice and what started me offering it routinely, not just as an afterthought for certain people or someone that comes in asking for it, was a friend of mine was speaking at a conference and saying, if it's your mother and she had knee arthritis, would you give her a steroid shot, a gel shot, knee replacement, or a regenerative medicine treatment if insurance wasn't an issue? And so obviously everyone's like, well, if insurance isn't an issue, then we would give a regen. And then you said, then what makes you think you have the right as a doctor to make that decision for your patients if they want to pay for it or not?

God, that guy's brilliant.

Yeah. Yeah, I use that. I tell patients this on a near daily basis.

Sounds like something I would say.

Yeah. I don't know if you still say it, but if you—

No, I do. But I mean, yeah, it's— you did a pretty good job of like Yeah.

And that was my— if I'm being like 100%, like, I have known Regen for years, but I never got to the point of feeling like it's okay to ask someone to pay for something in medicine. Like, you know, you think that it's a right too. It's a, you know, medicine's a service and a right too for patients.

Right.

And you try to do your best for people and not everyone can afford everything. So you want to just do what you've been trained to do, as some of our other people in Mavericks said, groomed to do.

Yep.

Through the way we're trained. And I realize it's not like an insurance company saying, hey, don't offer Regen, or like your mentors are saying, don't offer Regen. It just never comes up in the conversation because every person training the next generation not every person, but the majority are used to having their ideas in the insurance box.

Right.

So I tell my patients that I deal in the insurance box, but then I really deal in the science box, which is bigger than the insurance box. And then there's a voodoo box, which if you want to talk about, we can, but that's not something I generally recommend. So the science box is much bigger than the insurance box. And what's in the insurance box is usually reasonable. Not always, but usually reasonable. But what's in the science box is also reasonable. It's just not covered. So that is when, that's when that light bulb moment happened for me.

So the insurance box, I liken it to AI. Like, so if you go to ChatGPT or Claude and you ask it, like, we just got done with a 2-week trip down the coast, right? From Eureka, California, actually from Mount Shasta over to Eureka, California, all the way down US-1, all the way to LA. So like every good human being today, I went to chat and it helped me kind of plan the itinerary. But the thing that people don't realize about AI is it's going to give you the basic middle. So everybody's asking this question and what it's going to do is AI is going to say, oh, this is what everybody's asking. Here's what the answer is for everybody. And so what happens is that for most, for 90% of the people, 95% of the people, Using AI gives them a very bland, boring answer. Okay? It's the middle ground. It's the same thing with insurance-based care. Now, the reason why AI can do that, I'm sure they have legal implications. They don't want to get too far afield. If you've ever asked AI some really dicey questions, it'd be like, you need to check with a lawyer on that.

Yeah.

But we need to warn you that doing psychedelic mushrooms is Not that I've ever done them.

No, I'm kidding.

Of course I have. But it's illegal in these states and you need to watch all that stuff, right?

Right.

They're just covering their asses because they want it the middle of the road. That's what insurance wants. Insurance doesn't want to take any risk. They want as high a volume as they possibly can on the simplest thing that's going to get the best generalized outcome that they possibly can. So with AI, how do you get it to give you the answers on the fringe? You ask it tougher questions. And to me, that's what doctors are there for. But what the system has done is the system has made it so that you don't feel safe giving difficult answers because of lawsuits and all of that. And so what I always try to explain to people is when you're talking with your doctor, if they're not willing to really examine or look at things outside the middle norm. I'm not saying that doctor is not any good, but to me, a doctor is supposed to constantly be asking questions. When you hear me say that, how do you respond to that?

Well, I actually— I agree, but I also— I don't think that the problem is doctors not wanting to have the difficult conversations. I think a lot of us are used to having pretty difficult conversations and are willing to discuss the fringes. Like, I don't actually think regenerative medicine is on the fringes at all. I think it's a level of science.

I agree. And I bet I could put 10 other orthopedic surgeons in that chair and they would say it's risky.

Right. So the problem is not the risk. The problem is the lack of training in regenerative medicine.

So is it lack of training or lack of evidence?

Lack of training.

Okay.

Yeah, 100%. Yeah.

So trick question, by the way. I knew the answer. I knew the answer.

Yeah. So no, it's, this is the problem. So I'll give you a great example. I did a PRP and later stem cell procedure on one of my sister's good friends. And he's practically part of the family. So, you know, it was not a financial decision really for him. So we just did it. And his dad's an orthopedic surgeon who's, I think, just retired recently. I don't know.

Oh, really?

And he, at like in his late 30s, has like pretty severe knee arthritis to the point where, you know, he'll travel with my sister and they'll go somewhere as they're both their families. And he told me, he's like, they'd go on hikes and I'd have to sit it out at a coffee shop sometimes at like his late 30s.

Was he an athlete?

He tore his PCL at some point. Recently we found out his other knee has the same level of arthritis. So it's probably more of a genetic thing.

Genetic BS. God, that poor guy.

So, well, When I first met him, before I jumped to the regen world, he was getting cortisone shots before. And so he wanted a cortisone shot. And I'm like, this is not great for you. Let's try to avoid the cortisone shots. We did a cortisone shot. Eventually, they stopped working. And he's like, I'd rather just get a knee replacement. And I'm like—

So at 39, would you—

He was— at the time, I think he was saying that he was like 37, 38.

So what's the life of a knee replacement, 20 years?

If you're lucky, if you're unlucky—

So what do you do? What do you do at 59 or 55?

You get another one. And then if you're lucky, that goes, remember—

So 20 to 30% of the people aren't happy.

Already. And then you're closed. Right.

So then when it wears down at age mid-50s, you have to get another one. You don't have another choice.

Right. Right. And then the likelihood of that one being successful is lower than the first.

Yeah. Do you know the numbers?

I don't know the numbers, but every time we take it out, it, it's, you know, it grows into your bones. So you have to chisel away good bone. And so you, it becomes more and more complex every time. Nobody wants to do a second knee replacement. or third knee replacement as a surgeon. They prefer to do the easy first ones and then not have to ever look at it again. So, you know, like something I see in my clinic now as an aside was, like, people come in and a lot of orthopedic surgeons say, well, you're in your mid-60s, then it's— you're old enough, old enough to get a joint replacement, which I think is a bunch of nonsense because there's no old enough or young enough.

Well, think about getting it at 60. Now you know what— how long we're living, right? Now you're looking at 80, and then think about surgery at 80.

Well, that's exactly the point. So I have plenty of patients that come to me for a redo shoulder replacement when it falls apart at 80, and now they're sick and unhealthy. So I tell my patients, if you're going to do it, sweet spot's mid to late 70s, early 80s.

All right, so let's go back to your— I'm sorry, we went down a rabbit hole.

Yeah. So I asked this friend of mine who I did PRP on and then later stem cells on his other knee, I said, what did your dad think? And his answer was, oh, he thought it was bullshit. His dad's an orthopedic surgeon.

Right. So when he told him he was going to get the procedure, he thought it was bullshit, or after he had the procedure and he saw the results?

before, it was bullshit.

Okay.

And then what he said is he thought it was bullshit until he saw me go on a hike that I haven't gone with him in like 15 years or something like that. So, so the proof was in the pudding, you know? And the truth is, again, most of us don't get any exposure to any of this in our training. And we hear one of our mentors or friends say, oh, it's nonsense, because they see the outcomes of the crappy regenerative medicine, which is not even regenerative medicine.

Mm-hmm.

Or, you know, they're just assuming that surgery is the right answer. But most— the problem, I think, is not— it's just that people don't know. We're not trained to even think about it because it's not part of our routine conversation, and we don't see the good outcomes. The worst of it is there are very few high-quality regenerative medicine experts in the country.

Yeah.

That's one of the biggest problems. And I hate to say this, especially in a podcast, but I don't even blame that much the insurance companies because they don't have real data to be able to say, hey, it's good or it's bad because there's so many people doing it wrong, not following the science.

Right.

That the outcomes suck.

Right.

And so like I did a, this happened recently too. I had a patient, her husband had PRP with me and she happens to see a doctor whose husband is an orthopedic surgeon that just retired who also said it's nonsense. Don't go to that. Like, don't do that stuff. It's all like, Vui.

Vui, yeah.

But it's— the data is so clear and all you have to do is read it. It's— this is not— it's not controversial. What's controversial is— what's controversial is just your own limiting beliefs about regenerative medicine because you never bothered actually reading the journals. In residency, we have journal club. We read all the things like which surgery is better than the other and blah, blah, blah. There's not a single time that I read any articles about regenerative medicine in my training.

Well, the bigger issue is that we're more and more of a society, and it's not as big of an issue in the medical space, especially with doctors, because you're trained to read. You all have taught me how to read things that I never thought in a million years that I would read. And the biggest challenge though is that we live in a clickbait society that most people— I saw a statistic the other day, Most people, if they— 94% of Americans do not read a book after high school. Now think about that. 94% of Americans do not read a book after high school.

I believe it.

And the other statistic is something like Kindles were supposed to be revolutionizing people reading books. Something like less than 1% or less than 2% of people ever make it past the first 10 pages. So if you have a Kindle and they have the things that shows all the highlighting, you'll see in the first 10 pages, people highlight a bunch of things. And then in chapter 2, there's no group highlight. There's no— it goes from 25,000 people highlighted this sentence to in chapter 3, there's zero people highlighting.

Mm-hmm.

And so I think what that's indicative of is that people have become busier and busier, and especially in the medical space, You're spending 24% of your time doing paperwork, charting. You're seeing 50, 60 patients in a day. You don't have time to read. And if you do have time to read, you need somebody else to read it for you, and then you just take their word for it.

Right.

So I think that there's a huge— what I find in my work with orthopedic surgeons, pain management, those 2 particular areas, is they just don't have the time to educate themselves to the level that they want to. It's not that they don't want to. Yeah.

It's not just that. So just like I knew who Don Buford was as a human being and as a surgeon in his training, and I chose to take that leap of faith and— well, not really. He proved it to me in that conference that, you know, why I should trust him. And he showed the real data, which I've never seen before that conference with him because no one ever really talked about it. But just like you could, I got lucky in that I met him, opened up this world of regen beyond what my fellowship already did. If, if I didn't meet him, I would probably be doing regen to the level that my fellowship taught me, relatively basic. Although the surgery they taught me is very high level, but, and I would never know better. And then if someone said, oh, well, this regen could save someone from a knee replacement, I'd be like, eh, then I would've heard about it from one of my— Like mentors.

Yes, that's the key. I would've heard about him. Yeah.

'Cause they're, they are phenomenal doctors and surgeons that I work with. I have the utmost respect to them. I, to this day, again, I would never do half the things that I do if it weren't for them. And I told Don Buford at some point, 'cause I, you know, Steve Snyder, who's again, one of the fathers of shoulder arthroscopy and the most humble guy you'll ever meet, he revolutionized how I, well, how many of us, but for me personally, like I fix rotator cuffs to this day, almost exactly to the millimeter how he taught me. With other docs from SCOE who refined it, and I don't want to go through all the names just to pay homage.

Right. It's not the Oscars Awards.

But they're all— they taught me that. I told Don Buford, I'm like, you changed the trajectory of my career to the same degree as Steve Snyder did after a year of fellowship with him. from what you do with regenerative medicine, even though it was never a direct, like, one-on-one year-long mentorship.

Yeah.

So, and he has the same respect for Steve Snyder as I do, 'cause he trained under him. And so I, I, I'm just, I got lucky that I met Don. And so the problem is most of us don't meet somebody that's educated in regenerative medicine. And just like I could say a certain procedure in OB-GYN works or not, it's just because I heard that from somebody, but I am not an OB-GYN. For an orthopedic surgeon or pain doc to say regenerative medicine doesn't work because they heard it is not science. So that is exactly what they're saying is, well, regenerative medicine is— it's unpredictable, it doesn't work, it's voodoo. What they're saying is actually voodoo because they are just listening to— That's so well put. They're hearing the outcomes from a variety of people, some that do well, some that don't do well. We know we can inject saline into a knee and have some decent outcomes for a while, but they never bothered to read the data. So how do you say something's voodoo if you never read the data or even open to hearing about it? I think most of them are not. It's not that they're not open to hearing about it, it's that they're so busy.

I think they're so busy because there's what, 12,000-plus studies that show the efficacy of regenerative therapies?

I don't know about how many studies, but I know that there's—

Remember when— were you at the event where Dr. Roddy McGee got up? Was it AAO?

I wasn't there.

Oh, Ayo.

No, Ayo.

I'm sure he was. Yeah, it was classic. It was Ayo, Ayo. And, you know, Ariane Demers is there, Chactor's there, Roddy's there. There's probably about 10 of our clients there, right? And they finally, they did an entire afternoon on regenerative therapies. Donnie was there, right? And they bring Roddy up to talk about whether or not there's any evidence. Okay.

Oh yeah.

Okay. And you know Roddy.

Roddy's the right guy.

Roddy's the right guy. And it was one of those things. of those things where it was almost like you thought like Don and Arianna like planned this perfectly.

Yeah.

And I think Don had to go after, after Roddy did this. So here's what he did. So for those of you that don't know who Dr. Roddy McGee is, he's in Las Vegas and he has the driest, funniest sense of humor in the world. Like he would be in Mastermind, right? And he would just make some comment and the room would stop and then they'd just start laughing, right?

Yeah. And him and Jake, it's great.

Yeah, it's great. And there, if you're lucky, you sit next to him and you're like, it's, there's a comedy show. And I've, and, and he's a fun guy to out with. So anyway, they get Roddy up there, and Roddy is a typical orthopedic surgeon, right? Bone broken, bone fixed kind of thing, right?

You know what I mean?

You know, got a hammer. And so he's like, at first he's like, oh, my patients won't pay for it. He's going to be on the podcast a couple of weeks. And oh, you know, they won't pay for it in Las Vegas. Yeah, they will. And so he's like, but you know, is the science really there? And he's been on Joe Rogan. Like, he's treated a lot of like the UFC fighters, like way back in the day when they were doing third-party stem cells, that kind of stuff. And so he gets up and he goes, so I want to talk to everybody today that thinks that this stuff doesn't work. This is a room, this is 1,500 people in the conference, right? They do an entire 4-hour session on regen therapies. I want to talk to everybody in the room that doesn't think this stuff works. And he puts on The Who. Baba O'Reilly, you know, and he's playing the thing. And he goes, I'm just going to put 10% of the studies up that show that it doesn't work. And he's got the music and that song starts kind of slow and then it goes faster and faster and faster and faster. And he's just pumping. There's like— and he goes, that's 10% of the studies. And it was—

That's Roddy.

That's Roddy. Donny gets up there and he's like, I have no idea how to follow that. He's trying to talk about, don't get a code. There's no coding for it. Come see me, or something like that.

That's funny.

It was great. It was just— but there's so many. The point is, is there's so many studies, but they don't have the time to go to do it.

One of the core issues is not that they're not studies. The core issues are that the journal editors accept junk studies with things that are called—

Because they pay for advertising.

Yeah. No, I don't— I think that it's okay to think about, well— and I agree in a lot of ways, like insurance companies bad and all that. They're trying to limit us. But I don't even agree with that for this because I think the journal editors have the same issue where they don't know what PRP is. So when they get—

Because there's no central group that can write a big enough check to get their opinion on it.

Right. Well, so they're getting these well-done studies. So that's what they want for publication. But they're well done for an injection that is being called PRP, for example. But it's not PRP. It's like barely more platelets than what's in your blood. So again, you could have a study that has an 8cc blood draw and call it PRP, and it's done like a beautiful study and it shows it doesn't work compared to saline. Sure, no shit, because it has 8cc of blood and you're getting no platelets. There's no dose there compared to using 60 or 120cc and having a real platelet dose. The journal editors don't know that, yes, it's a well-done study with a non— like a crappy quality product that's being injected. So they publish this and it's just globally known as PRP doesn't work. Not PRP at this crappy dosage doesn't work. That's like saying Tylenol doesn't work for pain control when you sniff the pill.

Yeah, no shit.

Like you have to take the pill.

Right. Kind of helps.

And you have to know, like, there were studies that determined whether you want to do 325 or 500 or a gram, you know, where that right dose is. And we know at this point where the minimum is. But most people in a lot of those studies don't talk about that at all. And not because, again, bad people or bad surgeons or bad journal editors, but because it's a lack of knowledge. So I think that's being promulgated by all these studies coming out that are crappy and then the ones that are good. And the sad thing is, normally I tell patients, don't, you know, overdo the ChatGPT, but sure, go ahead with ChatGPT and ask what are the differences between good PRP or bad PRP?

But a patient's never going to ask that. You have to educate them. So when you do your videos, you got to say, let me show you how to use ChatGPT the right way. So you don't want to say, does, does PRP work?

Right. Because ChatGPT will say, oh, well, we don't— same thing. But if you ask—

We don't know.

But you can then ask ChatGPT or any of these AI things, what is— what makes good PRP versus bad? And it will come up with dosages and number of blood draws and all that. The sad thing is I've had patients come into my clinic that are like, oh, I had PRP, or I went for a PRP consult at this enter big name institution. And I asked them like, well, is it a single spin or is it a double spin system? How much? What? What's the dosage that I'm getting? And they had no idea, these like big name institutions.

Right.

And that's where I have to say like, these might be phenomenal surgeons and doctors. They just don't know Regen. A simple screening question for a patient. Now there's a lot of nuance to Regen, obviously, but the simplest screening question to ask if your doc knows what they're doing even a little bit is what dose platelets am I getting?

Mm-hmm.

If they—

Well, that's the trick question. Yeah, they won't know.

Then you're in the wrong place.

If you would have asked me that in 2015 when we started using the Magellan for doing PRP injections into the penis, I would have been like, what the hell are you talking about?

Didn't think the penis would come up in this podcast today.

I own a erectile dysfunction clinic. Come on. It always comes up.

Not the bone I'm used to working with.

Yeah, yeah, yeah. I know there is no physical bone in there. So in case you didn't know the— but yeah, I mean, you just, you know, I think about— I think back to when we first started doing PRP for erectile dysfunction. And for Peyronie's and all of that and venous leakage. We just drew 60 cc's out, we stuck it in the machine, we spun it, we got down to 8 cc's or 6 cc's, and we, we reinjected it back into the corpus cavernosum. I don't know what we were doing. Yeah, like, luckily I asked Donnie about it one day. I'm like, how was that Magellan machine? He goes, actually, it was pretty good. He said your platelet count was probably, yeah, you know, 3 to 4 billion. I'm like—

You just don't know until—

You just don't know. Yeah, that's why it's so important that you, like, I love when our doctors start counting their platelets and tracking it and tracking the results. And now, do you use DataBiologics for tracking results or do you use any registry?

I do. And so they're redoing their registry right now. So we're waiting for them to come up with a new system to, to, we paused and then we're coming back on.

That's why Luke probably won't call me back because he's busy doing that.

Yeah.

There's, I'm going to be in New York in like 2 weeks. I'm like, Luke.

There's some major changes they're doing. Yeah. And you don't even have to count, like, it's pretty intimidating, I think, for the general orthopedic surgeon or pain doc where this is not part of their day-to-day to get like a hemo analyzer or anything like that.

Mm-hmm.

But you can just simply have a kit that draws at least 60, if not 120 cc's of blood for a large joint and know that you're going to hit that minimum of 6 billion, ideally at least 10 billion platelets for like arthritis of the knee, for example. Almost no matter what, if you're doing 120 cc's, which is, and I used to, you know, do more 60s and then I'd give, I'd have people come in with a guarantee. If there's not making enough progress, I'd do 120. Now I just do 120 every single time because I found that the—

What do you spin it down to?

It depends on the joint. Yeah. Like I, the other day I had, um, someone with CMC joint arthritis and I spun it down to 2 cc's. Wow.

Holy shit. And, uh, but it's— Coming in hot.

Now it's, it's a lot, but there's no data that says too much is too much. Right.

Right.

It's, you know, you'll have your limiting returns, but it's very clear that there's There's no benefit.

There's no downside to increase. Yes, you'll have limiting returns if you go to whatever, 10 billion, you're not going to get 2x over 5 per se. Right.

Yeah. So for my clinic, something I decided really early when I left the hospital and started my own thing is it's not going to be the cheapest clinic, but it's going to be the no corners cut clinic. So instead of drawing 60 now, which I used to do more of because that's what the data showed, you want to get 60, that generally gets you the dosage you want. I do 120 because then I know even if— unless the patient's platelet count is so low that they're like life-threatening bleeding, they will hit that minimum number. So I don't have to send them for a separate blood test or anything like that on a routine basis. Now, if they're not making progress, different story, we start looking into more details, but that's so rare.

Do you have your patients do like go on an anti-inflammatory diet prior, do any supplementation with regards to gut biome hormones? You doing any H-bot, anything like that?

I'm not doing any hormone stuff. I also told myself I don't want to ever dabble in anything. be an expert. So typical— Unless I decide that I want to be an expert.

Every orthopedic surgeon that sat in that chair.

Yes.

And you don't need hormones right now, so you don't know how important they are.

So—

No, no, no.

I mean, so I would be open to hiring someone that, that does that well, but I don't want to— I never want to provide subpar medicine.

Yeah, I get it.

So I always want to offer patients the very best that I know, and I need to know the very best.

Yeah.

So, uh, but I do tell people, I'm pretty sure this is Arianna's line, that your body's a pharmacy.

Yep.

Right. So, so, you know, don't smoke, go for a nice walk if you can on a routine basis before you get this done. You know, don't take unnecessary medications, eat healthy. Like those things do matter. And some patients have actually turned that into, like, besides getting the injections, they'll go on like a weight loss journey and stuff. And I've had patients lose weight. One of the first guys that came in who had a knee replacement came to me to see me for a knee replacement. He was like 50-something. And he wanted a knee replacement. I talked to him about PRP. And I talked to him about the body's a pharmacy. And so he came and he's like, you know what? Let me try the PRP. Now he's playing basketball on a bone-on-bone knee arthritis with PRP, which PRP for bone-on-bone arthritis is less predictable. But he's 2 years out, happy as a clam, bone-on-bone arthritis, playing basketball with his kids in his 50s. And he liked his knee replacement, by the way. He's not one of the ones that hated it.

Great.

I have a guy like that too. He's 78 now. Plays pickleball 3 times a week. Came to me saying, I have a knee replacement. I'm told it looks great on x-ray, which it did. I looked at it and I don't like it and I want anything but for my bone-on-bone knee. And he's already gone through like unnecessary surgeries, like a knee scope.

Oh, wow.

Which I get it. His surgeon was just trying to do something that's not a knee replacement and he got worse. No surprise. 'Cause a knee scope on a bone-on-bone knee makes no sense. Again, I don't blame the surgeon for doing it because they're just trying to help. So I didn't even talk to him about PRP. I'm like, if your goals are playing pickleball, I can't promise that either way because that's a heavy-duty pivoting sport on a bone-on-bone knee. But the best thing I have for you is BMAC. And so we did that. He's now a year and a half out playing pickleball 3 to 5 times a week at 78, crushing people half his age. And his face is on the banner that we just put in that pickleball court.

Oh, that's perfect.

Ask me about my knee replacement versus my stem cell knee. And he's, he's loving it, right? So like people that say it doesn't work, you know, it's just, it's sad because until you see it, if you, if you see it, you can't unsee it.

If you are, if you are a doctor or even a patient, but let's just say you're a doctor listening to this and you've believed that Regen doesn't work, PRP, bone, BMAC, adipose, that it doesn't work. Let me know. And what we're going to do is I'll have you come to OrthoSono and spend 2 and a half days in Vegas and listen, because your world will be changed.

And I'll do an open invitation to anyone that sees this podcast if they want to come spend a couple of days with me in the office just to see patients that are over a year out from Regen and ask them how they're doing.

Perfect.

So I had another guy, I replaced his shoulder 2 and a half years ago. I just saw him a week ago. And I PRP'd his other shoulder because I gave him the option, right? And he's a year and a half out from PRP, bone-on-bone arthritis of the shoulder, 2 and a half years out from his shoulder replacement. And he just did a video for us and I'm like, well, so what do you think? He's like, I like both of them, but I hated the rehab. It took almost a year out of my life.

Yeah.

And yeah, I mean, shoulder—

Sucks.

I love shoulder replacement surgery and it's great for the right person. But what I ask my patients every time they come in, I say, is it pain or is it function? And if they're going like this and they can't lift their arm up and they're saying, well, I can't— I could live with the pain, but I can't move, they need a surgery. They need a mechanical solution to their mechanical problem. If they say it's pain, even when it's pretty bad, you could potentially help them with Regen. Not always.

Right.

It's not 100% success rate. Neither is surgery. But I would argue that some Regen for the right things has a higher success rate than surgeries we do for the same indications.

Well, it's— and Ron Paul has been here and sat in that chair. And I mean, he's, you know, he's a walking encyclopedia of all the data. And he sat here for an hour and a half and just shared data about the progress that we're seeing in the last 10 years of the outcomes, like what we have learned. I mean, we're at that stage where we are learning so fast about the adjustments and the changes because now we have more and more doctors putting in new registries. Like a data biologics and getting the outcomes that we have doctors all over the globe now. We have clients in England, we have clients in Austria— Australia, not Austria. And they're living off the data that you're creating and learning that, and they're expanding it out. So it's really starting to pick up some amazing speed.

And the sad thing is most of us as orthopedic surgeons are used to level 4 evidence. Oh, surgeon A did a surgery that did well for 20 people. It must be a good surgery. And we understand that it's not as good as level 1 evidence, but it's hard to like do a fake surgery versus a real surgery, right? So you can't, and double-blind that where you're going to blind the surgeon, you know, when he does a surgery, you can't do that with surgery.

I think they should do blindfold surgeries. What do you think?

Probably make it work.

Yeah. You'd probably be able to do it.

It's better than not knowing what you inject with PRP, probably.

Yeah, probably. Or knee-ish, or like not doing it with ultrasound guidance and just, it's in the knee. I know the joint. Yeah, I love it. I know the knee joint.

But my point is the— I lost my point.

That's all right. So let's do this. I'm curious. So I want people to understand a little bit about your journey.

Yeah.

So you've been out of— you got out of residency in '18, 2018.

Yeah. Fellowship 2019.

Fellowship 2019. And you started your practice in what year? When did you start your first— your cash, your own individual?

2024.

2024. Okay. And you were working where? When you, did you leave? Tell everybody a little bit about this journey. I, and I'm gonna let you kind of guide this a little bit 'cause I know you have to be a little bit careful with some, some things, but.

Well, yeah, so I was, you know, I left a practice that sold to private equity that I initially thought I'd be at forever. And I thought it was a great gig and for the right person it probably would've been a pretty good gig. But I realized it was all about, well, it sold to private equity, so the original, dreams of partnership and what that would bring were never, were, were never gonna be realized at that point. So I left that because I would be a perpetual associate.

Yep.

And I just, that's just not what I was looking for. Yeah.

PE's not gonna make you a partner.

Yeah. Then I joined a hospital group and ran into some of the same issues that private equity and like private practice would've brought. And it's a—

did that hospital group, were they still independent or had they brought on private equity?

No, no, it was, it was an independent group sort of that was mostly owned by the hospital.

Okay.

And I don't want to go into some of the details. Yeah, yeah, I understand that happened. But, you know, there were things like it was a Catholic institution, which I'm not Catholic, but I read their tenets of medicine and I'm like all on board of if I could take care of someone that can't take care of themselves or can't afford to pay, And I realized that it just, in the end, it's still a business. Like, and I get it, like you have to keep the place open and, but you couldn't always take care of people that needed care for free, even if you offered it.

Mm-hmm.

Because then the hospital lost money and then they can't afford it. And I, I don't blame 'em. Again, I get it. Like hospitals are going under everywhere. But, uh, that happened and I realized, um, everything's about numbers. Everywhere. It's all about quantity over quality. And I thought there was no out. I thought that that's just what medicine is anymore. And it's— I actually thought it was impossible to run your own practice. I thought that that age is over.

And you were what, 36 at the time when you were probably 30?

35, 36.

35, 36. Okay.

Yeah. I just was like, okay. So I tried to run medicine my way as well as I could. I gave people as much time as I could. I I was never rushed in new patient visits. Maybe not never, but I tried to never be. I'd call people after hours sometimes to talk to them more if I didn't think it was enough time. And I tried to kind of make it work. But there's always those middle managers, people that are not involved with patient care at all, that are breathing over your neck saying, when can you see the next 10 extra patients? And sometimes you can.

Yeah.

But you can't— you just— When costs are rising of personnel and reimbursements from insurance companies are going down, and then you have to see more patients to be able to afford opening the doors, which then you have to hire more people to staff those doors. It's like just a never-ending rat race.

No, it's, and it's a, it's a race. It's a race to be on the bottom.

And then you have to sell to private equity or, or fold into a hospital.

Mm-hmm.

So, you know, I learned pretty quickly that I was a loss leader for the hospital and the office, like meaning Me being in the office doesn't make the money. Being in the OR makes the money. That's how it works just in general. Like, the reimbursements don't keep up. And so I thought originally, like, the way I started was actually I texted Don Buford the stupidest message for a guy that's incredibly busy and probably has a million people text him all the time. I texted him a picture of the logo I was thinking of making for a practice I wanted to start. Where I was thinking I was just gonna do some workers' compensation work, you know?

So you, you were gonna leave the hospital group, you were gonna start your own thing, put out your own shingle?

Yeah. And I didn't know that I was leaving necessarily yet, but I was like, let me, I want, I need a way out where I could at least control how many patients I'm seeing a day so I could give them more time. And my plan was I'm gonna do enough workers' compensation, which is much more, it just pays better. The insurance companies pay more, the medical legal work pays more, and you could stay honest with it. You don't have to do like some people sell out to work comp. That is not what I was doing. And I was like, I'm going to do enough of that so I could keep my doors open and then take a loss in insurance and just see patients and not care what it pays. And that message to Don came back as, hey, you should come to the BOB.

Right. Which, for those of you that don't know, it was the Business of Orthobiologics that Dr. Arianna Demers and I did twice. And it was an event where half of the sessions were about orthobiologics and the other half were about Right. And so that was an event that we ran with Dr. Demers for a couple years. So.

Yeah. So I went from that to that and thinking that my way out was making enough revenue from workers' compensation to afford taking care of grandma with a shoulder problem and not care what it pays to, hey, there's another potential way out. So I signed up with Mavericks at the Bob, even though I didn't have a place, I barely had a logo. And I was like, you know what? This has to work. And I came back saying, and I negotiated a day off per week. to do this. And I was fully intent on just doing a day off and just focusing.

So you were just gonna moonlight doing, basically moonlight doing this one day a week?

Yeah, that, that was the plan so that I could at least, you know, and I took a, a pay cut and all that stuff and I'm like, listen, pay me less. I'll see fewer patients. I'll take care of them. Eventually it just didn't. A new administration came to the hospital too. It just, it wasn't working. You know, it just, it, it, and I, I think I was naive to think that it would've worked where I could grow one thing and just because they—

Yeah. You worked That's all right.

Yeah.

It's okay.

And they didn't provide that service.

It started, you know, at least you started, it started you on the path.

Yeah.

That naivete is very key.

I wasn't trying to like, like I wanted to make both things work, right? But it didn't. And thank God it didn't because now I'm on my own and it's great. Everyone was trying to convince me to just fully leave right away and probably would've been the right answer. But I'm glad I used that a little bit just because it gave me some time to figure this out.

Look, it worked for you, right? There's, this is, you know, we get asked this question a lot. Like we get a lot of questions From a lot of doctors. I'm working for the hospital group. I've got a non-compete or I, you know, non-circumvent or whatever. I have no patient list. I'm making whatever, half million, $700,000, whatever it is. Right. We have a client right now. He's making $700 grand a year, right? Kind of in your age group. And he's leaving the— he's like walking out cold turkey, gave his like 6-month notice and he's getting out, walking out cold turkey. Now his wife's also a doctor, so that helps.

Right. Right.

I think she's a urologist. But anyway, the thing is, is that what was that like for you to start to do that? So you were doing it one day a week and you were— how did you get patients? What can you share? I mean, I know some of it you're— we talked offline that you, you know, I'll let you kind of just guide that a little bit into what you want to share about that.

Yeah. So, you know, patients found me, I found them. Sometimes it was— I negotiated my contract that the stuff that I was doing there is separate. So that was fine.

In the clinic that you were starting, it was completely separate. Yeah.

Okay. It wasn't—

So there happened to be a patient that had come into the hospital and they happened to find you and go there. There wasn't a conflict of interest?

No. And I also promised them that if someone needed surgery, I'd bring them back.

Yeah.

And I did. I've done that multiple times. Yeah. So I followed through with what I promised them. But yeah, it just started the difference from the Bob. What happened was I started offering regenerative medicine. For every science-based indicated patient, not just when the patient brought it up or when I was like, oh, this is an athlete that wants to go back to play faster. And so some internal drivers like, okay, maybe they'll think it's worth the cost. That's what changed. And that's what also led to the revenue that increased because people choose to avoid surgery. And no shit, obviously, like people want to avoid surgery whenever it's reasonable. And sometimes I still tell patients, this is not reasonable. You need a surgery.

Mm-hmm.

Because that is the case. And so it's nice as a surgeon. And again, I went into sports because it's minimally invasive orthopedic surgery. It's not like we just treat athletes. So Regen's great because it's the least invasive way I could treat somebody with real long-term solutions for the right problems. So that was my gateway in doing that one day a week.

And then how long did it take for you to— so you're doing that one day a week. How long did it take for you to realize, hey, I could be doing this full-time and this could work? Did you then go to 2 days a week? Did you go to part-time or did you just cut off cold turkey? And what was that timeline like?

Yeah, so it was kind of fast actually.

It was really fast. If I remember correctly, it was really fast.

Yeah, it was fast because I just decided to believe in the process and make— I'm like, this has to work.

What was that like? Was that scary?

Yes. I mean, I knew I could always fall back on what I used to do, right? But the problem is once you realize that you could— for me, my own practice is not just about growing revenue or— it's about controlling patient experience, right? I always said before I even started, I'm like, I want patients to be wowed from the sign to the first step into the door to the first person they meet and all the way back out. I hated, and I used to think when I was a kid and I wanted to be a doctor, and I remember people treating my parents or family members crappy on the phone or whatever, at doctor's office, because everyone gets jaded. I'm like, oh, someday I'll have my own clinic and I'll secret shop my own people. And then I as part of one of my practices, I don't want to name which one, there was someone that answered the phone that everybody knew was just so incredibly rude to patients. And I brought it up repeatedly. And I'm the last person to push that too hard because I don't want to lose somebody's livelihood, right? And I brought it up multiple times. And then the last time I brought it up before I left, this was one of the things that pushed me out because they kept saying, oh, they're being disciplined. They're being disciplined. And I'm like, at what point is that discipline turning into action?

Right.

And the response I got is, well, what do you expect? You get what you pay for. And they can't pay them more because that's just the way it, it works.

It is. Yeah. Because, yep.

So yeah, so that, that was one of my pushes. But so anyway, so yeah, I subleased from a friend of mine who's a podiatrist and like from a closet space essentially.

By the way, all podiatrists listening to this, you totally can. We're helping podiatrists too. We're gonna start, we, we got a couple that are just a year in and they're like killing it.

I got her.

So they'll be like, yeah. Yeah, it's amazing. Podiatrists, it's a fricking— you're, you're missing, you're leaving a ton of money on the table.

So I, anyway, I started subleasing from her place in May. So I went to the Bob in March.

Yep.

It was March 2024.

24.

I did my first regen day, May 17th, I think it was. And she hired another doctor at some point and I knew that was gonna get tighter. Mm-hmm. 'Cause she was off one day. That's just how it worked out. And I went to look at places just to see. And there was a place I looked at that was like 1,500 square feet. And I was like, eh. And it was like $5,000 a month. And I'm like, this isn't for me. And then the owner sent a message to the realtor saying, hey, why don't you see this urgent care that's closed? It's 4,000 square feet. And I'm like, I can't even afford the 1,500 square foot place. I remember talking to you about it.

Mm-hmm.

And he said, and then I got the message again through a realtor. He believes in what I'm doing. He has a concierge doc himself. And he offered it to me for practically the same price as a 1,500-square-foot place for the first year. And then it, you know, went way up.

Yeah, that's awesome.

He's like, when you're successful, and I think you will be, then it'll work out for me too. And he was right, you know? And so I, I have a lot of—

Hey, listen, there's that Splendid speaking to you, whisper out its ear.

Yeah. So he really—

Do you think about that? Like, like I'm listening to your story, you had a lot of whispers that you followed that didn't make a whole lot of sense, did it?

Yeah, I guess it didn't make that much sense, but that was November.

Yeah.

November 1st.

Of '24.

Of 24 is when I started that lease. And so, I don't remember anymore if I started seeing patients immediately, but I spent my days finishing one job, going there, building out the place, like freaking putting slats in the wall. Oh, speaking of whispers, the other thing that happened is my surgical scheduler who was at my prior office left. And I— this happened to me multiple times in both of my prior jobs. Where someone that's really good, like, confided in me that they're not happy. And I went to the administration or whoever's involved and said, hey, they're going to leave. You need to keep them. And every time they ended up leaving and the administrators are like, no, they'll stay. They never stay. And so I remember joking with her, oh, someday if I could start our own practice, I would hire you. And this was like totally as a joke. This was before I even met you. And so she left. And so I opened this place, I needed to staff it, and I still was working 4 days a week at the hospital. And I'm like, well, I could staff it like 1 day a week and I'll just sit there or whatever. I'll figure it out. And I just happened to talk to this person who left and went to another practice. And she was like hating it, in tears, practically hated it, asked for her old job back. And all the bureaucracy there kept them from making a decision of offering her a job back, which she was one of their best. employees, if not the best. And so I just hired her. I didn't have the money to pay her. I didn't know what she'd be doing. She ended up painting the walls. She offered. I mean, this is the kind of person she is. She's like, I knew she's the kind of person I'd hire and I could trust to just try her best, do her best. So it's rare you find somebody like that. And so that's kind of how it started, November 1st. She was sitting there, she was painting, she was trying to help. I didn't give the best guidance 'cause I was busy 4 days a week.

Right, right.

So, you know, she'd be sitting there watching shows sometimes, and that's fine 'cause there was nothing for her to do, right? And then it went from that to her painting walls. Now she's like the office manager. We went from 1 employee to 5 in less than a year. It was a year, a year August 11th that I was solo. Non-compete thing went away and As far as the non-compete.

How was the non-compete?

Yeah.

Because that's a big question we get. What can you share about that?

What can I share about that?

Because I'm sure you have a non-compete about talking about the non-compete.

Yeah. So—

That's generally how that goes.

What I would say is, I think sometimes you could get out of it easily, but easily isn't always what feels ethical. to you as a doctor, I would say. And so I didn't choose the easy way out, which sucked for a while.

Did it get a little dicey?

It got dicey. But eventually, even though it was a costly thing, it worked out. And, you know, I'm still like bringing cases to the hospital where I left and stuff like that. So, and I love the docs that I work with there. And so like, It's cordial from that end. Like more than cordial, we're friendly. It's just that, you know, these places, a business is a business sometimes. And the long-term relationships don't always matter as much to people as a short-term. And sometimes showing, making a point out of somebody. But also a lot of states have now practically outlawed non-competes.

Yeah.

Federally, that didn't work. But on a state level, like even in Pennsylvania, which is where I'm at, They, with very certain exceptions, there are really no non-competes, but they didn't apply retroactively towards my contract. So public policy is obviously going towards getting rid of non-competes for doctors.

Well, getting rid of non-competes in general. So for example, we've had some clients come to us from Colorado, and Colorado has passed a state law that non-competes are no longer viable.

Yeah.

No one has tested Like, okay, so if the non-compete, the law went into place, let's say January 1st, 2024. Does that mean somebody who signed the contract on December 31st, 2023, that the same— no one's really tested.

So that's what, that was my situation.

Okay.

But for, in Pennsylvania, it was specifically did not apply to prior contracts. So that's where things got dicey. And even, it's just, I think you have to make a decision on what you really want.

Mm-hmm.

And then just decide and, and do it. Now, the, the sad thing is, and this is a problem I think in general in the country, is that you don't have to be right to win legally.

Right.

You just have to have clout behind you financially. And so obviously hospital systems and big private practices are gonna have more clout than most physicians, let alone someone like me who Didn't have a ton of savings or anything like that to fight it. So that was, that was the scariest part in that. I was like, I don't know when I'm gonna run outta money fighting this, whether the business would build fast enough to offset the losses. So it was a hard decision. And at times after I made it, there were times I thought about, man, maybe I should have taken the easy way out. But in the end it worked out and I'm proud that I didn't take that easy way out.

And you're free, you're completely free.

I am pretty much free.

Almost. Pretty much free. Okay. Yeah.

It ended up essentially being what I offered originally without going into the details. Yeah.

And while you have a financial decision about whether or not you want to hire the attorney to fight, while the hospital has in-house counsel, they have their own lawyer on staff, which technically means that it's less expensive. They still have a financial decision to make. Because that lawyer or that group of lawyers doesn't have unlimited resources.

Well, I'm trying to see what I could say without it being too much. But what I would say— this is not part of any agreement, but just in general, hospitals have a great way to make physicians feel not valuable to them. And they think— and they are correct in thinking that most orthopedic surgeons don't understand the value they bring to the system beyond just the surgeries they do. And part of that's probably because insurance companies reimburse us less and less and less and less. And so we think our value is that.

Mm-hmm.

But to a hospital system, like, an orthopedic surgeon is a big deal. And the sad thing is, like, we lost so many orthopedic surgeons in this hospital system before I even joined over years. And they kept telling the orthopedic surgeons that stayed, hey, Cover more and more call.

Right.

And they're like, oh, well, we're trying to hire. And they never really tried to hire. And they wanted us to cover call for free, which is crazy. 'Cause it went from having call split over, I think at some point they had like 10, to then it was getting to a point of 6 or something like that, or 7, uh, or 5. It was gonna go down to 5 'cause a couple people left. And eventually, like I was saying, like, you guys are acting like residents, you know, like you're just, Because they're telling them, we can't afford to pay for call, right?

Right.

And so eventually, the orthopedic group decided, you know what? Yeah, we have to be paid for call after this date. So we all took a bunch of free call for a while. And eventually, they settled on, we'll take call for a rate. And that rate is $750 a night, which is way, way below the average rate for orthopedic surgeons.

$750 a night?

Yes. And, but what's worse is from, in my situation, it was not all in-house counsel, it was outside counsel too. And I know for a fact that they were paying more per hour for—

Than what?

Yeah. Than what they offered us for call for a night. So, and, and they kept at it, you know, like obviously, like without disclosing details, which I don't wanna disclose, you know, lawyers were involved and lawyers are expensive. They were expensive for me and I'm sure they were more expensive for the hospital eventually.

And you have to understand, hospitals are not ginning money anymore.

Well, that's what I—

And even in big cities like Philadelphia, I mean, they are struggling. A friend of mine just bought a group of hospitals in Kentucky. They had lost something like $16 million, this group, the year before. He bought them about 2 years ago. He— no, they lost $6 million. He got them to $16 million profitability. And of course he's selling them off. But that's just, I mean, that's the indication. His business model is he buys failing hospital groups. This is what this guy does for a living.

So that's what really confused me early, because I'm like, I will continue to do cases here. And because I knew I was a loss leader in the office, I'm like, great, you don't have to pay me. I'll still do the surgeries. And yet it still led to this. And I'm sure, again, the business of it fell into it, but I never understood. I'm like, for a struggling hospital to be spending any amount of money and then saying they can't afford to to pay orthopedic surgeons to take more calls. And then the worst of it, like, there were days that were uncovered. So patients would be transferred from the hospital to another hospital with pretty simple orthopedic injuries because there's no one to do it.

Jesus.

Next day. And that's a huge loss for them too. So, like, the— I happened to learn relatively early in my career that big systems like that don't move well. And at some point, they actually asked me before things went to me leaving fully because I I actually offered to stay involved in some way more directly, which was a mistake, and I'm glad it didn't work out. But they were like, well, can we essentially get you fully back in with your practice that you started? And I'm like, you guys, like, the whole purpose of me doing it on my own is that you guys just, you can't move. They're like, oh, we'll move quickly. No, you won't. That's like saying a bus can move faster than a Ferrari. Like, I could tomorrow, like, a simple thing is, a dirty tile or a leak that went through and there's a stain on the tile, that stain's going to be in the hospital for the next 30 years, guaranteed.

Mm-hmm.

In my office, I'll be like, there's a stain on the ceiling tile, get me a new ceiling tile. Because it sounds like a no big deal. Or another example, like, we have really simple things like Fiji and Pellegrino in the office for everyone who sits in the waiting room. We have a little coffee menu called Iron Mountain Summit Sips. And we have a little latte machine, all this stuff for people. It's not like just a Keurig. There's no chance a hospital—

No.

Just, oh, by the way, the same, most of these hospitals are getting rid of simple coffee machines in the doctor's lounges. Like for me, I'm doing a surgery—

When you have to start cutting 75 cents for coffee because—

Oh, it's, they don't—

In the doctor's lounge?

Yeah.

When you have to start doing that, you're in trouble.

Well, in the last couple years, coffee machines disappeared from the floors. The cafeteria closes at, I don't know, 4 or 5, whatever it is. I was just there doing surgery till like 9 o'clock a couple weeks ago, and I went to try to find like an ounce of coffee anywhere, and I couldn't find it. And the physician lounge has nothing. Like nothing. There's a Keurig machine, but there are no cups. And like—

Just put your mouth underneath it.

You know, you hear from other people in other places, like people are not buying paper plates anymore. Like they're not providing that for staff, just paper plates. And like, yeah, it's, that's, They're cutting those costs because they think that's what matters, but the amount of money—

No, they're cutting it because they're trying to do anything they possibly can to make the P&L and the cash flow statements look better so they can, because they only want to own it for 3 to 5 years, and they're all looking for the next person to buy.

Well, what they don't realize is that kills morale.

PE has ruined— PE is, it's not the only thing that has ruined modern medicine, but it's a major league fucking contributor.

Well, you know, PE doesn't own the hospital that I was working at, but in the end, it's, I mean, they don't get paid enough by the insurance companies to—

Well, PE's into the insurance companies, private equity, right? Funds own, they own huge chunks of the stock and they look, you know, the funny thing is, is we joke about this. We were having this conversation the other day in the company. Well, who's releasing the latest? Who's releasing— oh, Lilly. Eli Lilly's releasing tirzepatide, or whatever, the latest version of semaglutide, the GLP-1. And so we were all joking, yeah, we need to go buy Eli Lilly stock, and then when we sell it, we can save that to just go out and buy the peptides that we want to buy. So we're going to go invest in the thing that we hate to go fund the thing that we love, right?

Yeah.

And I just think that there's going to be a lot of that.

Yeah, it's not getting any better.

That's for sure. As a doctor, what saddens you the most about modern-day medicine?

I think what saddens me the very most is that doctors no longer tell children that it's a good path.

Hmm.

You know, if I—

and you knew at a young age, right? When did you know?

I don't know, 5, something like that.

5 or 6.

You know, it was silly then, but it stuck. And it was not anyone ever pushing it on me. But that's the saddest, because even when I was applying to med schools and stuff and shadowing doctors, even for me then, they were like, oh, I've had people, orthopedic surgeons say, why would you ever want to do this? Like, I don't know if I could give you one piece of advice, change your mind, find something else. That's the thing that saddens me the most. Because it's— and it's a— why could you— how could you blame them?

No, you can't blame them.

Because now they used to be respected and trusted, and they were able to practice more freely and have their own practices and treat patients the way they wanted to treat them. And some were better, some were worse. Now the system forces them to see more and more people, get paid less and less, work their asses off, treat patients with the— I just read a study from 2025. I hate to not have the quote who it's from, but that the average patient visit with an orthopedic surgeon in this group, I think they had like 10 surgeons and almost 1,400 encounters, was 7 minutes and 52 seconds.

Jesus.

And so how could you provide that care?

How can you verify date of birth and name?

Well, I mean, that's MAs, but the point is just you are becoming a robot. And then they come home often and they're dictating at home. They're doing the charts at home.

Mm-hmm.

And so they're missing out on their own family life. In the meantime, most of us have given up our 20s just to get here thinking, oh, it's going to get better any moment now. And then you realize that you're stuck in this rat race of seeing 50 patients a day, coming home, dictating a couple hours. Like one of the guys that worked in my old practice, he's in his late 60s and he's still— I know he does charts for like 2 hours at night.

So it was Ash Goyal. Ash Goyal would come home, 6 o'clock, have dinner, and then spend the next 3 hours charting.

And I'm like, that? So of course they're not happy, and they don't want anyone to do it. And what's even worse, you take that with doctors already burning out, and then you have patients that don't trust their doctors, and they think that doctors are all part of this system. And also for good reasons sometimes, because they get 7 minutes to spend with the doctor, And it's barely a conversation before the steroid injection comes into play, right? So the system is forcing both patients and doctors to be in a crappy environment, which is burning everybody out and getting the patients to distrust the system and the doctors to hate their lives and burn out and not recommend it for young people. The brightest and smartest that used to go into things to try to help people are now going into other things that are more focused on helping themselves sometimes. Which is okay. And, or helping people in other ways. It's just that medicine is becoming roboticized before even AI had a chance to take over.

It's becoming roboticized. And then on top of it, it's, I think, again, private equity to me is one of the worst things that's ever happened to medicine because they try to make it like you're making cheeseburgers.

Well, yeah, I mean, that's their job. Right.

They're good enough. And that's— look, and that's what they're paid to do is they're fine. But it doesn't— I will tell you this. When I first owned the ED clinics, I had that approach of, hey, we got to— one of our KPIs was how long were you staying with the patient? I mean, it was pretty straightforward, right? The visit shouldn't take more than 15 minutes, right? 15 to 20 minutes, and then you give them a trimix shot. And I used to get so frustrated because our doctor— and I wrongly got frustrated. I've since told him, I said I was wrong. At first I was like, why are you spending like 45 minutes? And he's like, well, he had a bunch of other questions and no other doctor would answer for him. And it took me about 6 months to realize. I'm like, oh, fuck.

Yep.

And this was 2014. And I'm like, okay, that makes sense. I didn't realize— I was just coming in from a business standpoint. And I can see how the people at private equity, they don't understand. I mean, but when you You know, owning clinics for years, and then, you know, sometimes I'll hang out in the office and shadow you all if I'm in town. The hunger from the patient that just wants somebody to give them some straight answers and spend some time. How long do you spend with your patients when they come in?

New patients get 45 minutes to an hour.

How's that?

You know what's funny? Sometimes I feel rushed. So weird, right? So I have to actually consciously still realize that, and most of my patients that have any procedure done, certainly surgery or regen procedure, get my cell phone.

And you're still doing surgery, just so everybody, like, you still do surgery?

Oh yeah. Surgery's my calling. Regenerative medicine is part of that. Because I shouldn't be operating on someone that doesn't need it.

Right.

Right? That's really what it is. That's like the whole identity of my practice is I'm a surgeon who's going to give you every option that makes sense, whether it's surgery, not surgery, or just living with it, which you can't believe how many patients I see. A simple example, again, I do shoulder replacements, I do complex shoulder replacements and redo shoulder replacements. And then someone's sent to me by another orthopedic surgeon saying, I'm told I need a shoulder replacement. Great. Well, you don't need a shoulder replacement until you come in begging for it. And their eyes are like—

Yep.

Well, then I don't want one. And you don't even realize as a doctor that when you tell a patient you need a shoulder replacement, a lot of patients believe that, like, flatly, exactly how it is. Oh, I must need it. Not you need it if you can't live with it.

Right.

They think if we— like, I had another lady came in, She had bone-on-bone arthritis. She saw another surgeon, and he told her, you're going to end up in a wheelchair if you don't get your knees replaced. And she comes to me for a second opinion. I'm like, okay, great. So where do they hurt? How much do they hurt? And she's like, well, they don't really hurt that much right now. And I'm like, then why would you get a knee replacement if they don't hurt? You're walking. What's the problem? She's like, I don't really have a problem, but he told me I'm going to end up in a wheelchair if I don't get them replaced.

I had something similar with my college friend's wife.

So I'm like, you know, we don't— But we don't realize that because we have 7 minutes to spend with a patient and we're just saying, oh yeah, bone-on-bone arthritis. You, you're not gonna be able to walk eventually. Maybe we don't know that. 'Cause there are plenty of people with, I tell people, I don't treat your pictures, I treat you because there are people with bone-on-bone arthritis all over the world that don't realize they have bone-on-bone arthritis right now. And that's actually part of the things that got me into regenerative medicine because I would see someone with bone-on-bone arthritis as a, in my training and someone with mild arthritis and the person with mild arthritis says, cut my knee off. And then with bone-on-bone, I was like, oh, I just realized it's a little creaky.

Yeah, it's a little creaky. It hurts a little bit.

And so our bodies have a great capacity to adapt to what we have. All that Regen does, it's not magic. I wish it wasn't called regenerative medicine because it doesn't regenerate things. It does sometimes.

Orthobiologics is a good name.

But all it does, it helps your body adapt to what you have, which many of us do naturally. Yeah.

So we're out of time. If people want to find out more about who you are and what you do, what would be the best way? You want them to go to your website? What would—

Whatever they want to do is fine. My website's ironmountainortho.com. You can find me on LinkedIn. Again, if anyone wants to actually come see patient outcomes, just contact the office. If someone across the street from my clinic wants to come see how to do it right, I don't believe in competition. I just believe in doing the best job for our patients, and there will always be patients that could use us. Anyone wants to stop by is always welcome.

Cool. Thanks, Mark. I appreciate it. Yeah. And great. Enjoyed the conversation. And next time you're in LA, I know you'll reach out, but let's get you on again. Okay?

Sounds good.

All right, buddy.

Thanks. Appreciate it.

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