Episode 33: How Dr. Zwade Marshall Uses Referrals To Grow His Business In Pain Practice

Jan 27, 2020

This Episode

Interview w/ Dr. Zwade Marshall

You Will Learn

 You will learn:
– How Dr. Marshall’s fight with severe asthma as a young child effected what he does today.
– Dr. Marshall’s tips for business students.
– The importance of the discussion of economics and medicine.
– Where Dr. Marshall gets a majority of his referrals from.

Resources & Links

In this episode, Justin talks to Dr. Zwade Marshall about the importance of referrals, and the easy steps that you can take to strengthen your relationships with business owners, peers, and clients.

Justin: [00:51] Hello everybody welcome to episode 33 of the Anesthesia Success Podcast. I’m very excited to be joined today by doctors why they Marshall so my day is double board certified in anesthesiology and pain management. He’s an innovator. He’s an entrepreneur. Right now he’s working hard to solve problems not only for his patients but also for young physicians. So I couldn’t be more pleased to have him here welcomes one day.
Dr. Marshall: [01:13] Justin thank you very much for that kind introduction. It’s a privilege to be here. I’ve become a fan of your podcast. Lately I’ve I heard Dr. Tim dear on here not so long ago and then I listened to the the episode about whole life insurance as well as how that was. It’s pretty top of mind so it’s it’s a it’s a I hear a lot about that.
Justin: [01:34] That’s right. That’s one of those one of those episodes that I wish was not as applicable as it unfortunately is. Sure sure.
Dr. Marshall: [01:40] Well thanks for having me. As you said I am a I’m currently the co-founder for to doc lending I’m an anesthesiologist as you said an interventional pain management specialist. I’m the director of outcomes for alliance spine and pain in Atlanta Georgia. And so in that capacity I helped to recruit and interview new doctors and so I’ve got some tips for how to kind of navigate the private practice interview trail but then also I kind of look at the opioid prescribing patterns with the practice and I try to put some thoughtful policy around that part of things as well. Prior to being at Alliance I was in Boston at Harvard for my residency and fellowship and before that I was in Atlanta at Emory for my medical school business school and college. So. So I’m I mean I’m unemployed and it feels as painful as the homonym hemorrhoid because I’ve got the student loan debt to show for it and so I’ll go Well I’m I’m there’s so much here I’m really excited to talk to you about each of these topics let’s start just a little bit.
Justin: [02:44] Tell us about yourself and your story and what made you want to be a doctor and then what incline you also to be a physician entrepreneur.
Dr. Marshall: [02:51] Sure. So I think I have one of those fairly typical immigrant stories. I moved to the U.S. with my mom and sister when I was 16 years old came from Guyana.
Dr. Marshall: [03:03] And usually people say Where are you from. Tell going to have to kind of tell them that it’s in South America not Africa. And then add that it was a British colony that’s why I speak English so well but it’s neither in South America more Caribbean in culture than anything else. And I think being from Guyana I think it kind of motivates your your ability to aspire to achieve right. My mom was a seamstress and and worked to provide for my sister and me and she was a tiger mom that really valued educational accomplishment and so I was a pleaser child and wanted to keep her happy. And I was fiercely competitive too. I think that also helped to kind of get me to where I am now. But why medicine. I mean from one of those cultures in which you know if you do well in school you’re going to be a doctor a lawyer an engineer right.
Dr. Marshall: [03:55] But but I was I interacted with health care a lot. I had really severe childhood asthma and I think that when you struggled to breathe and you in the third world and you and folks actually die from asthma where I’m from I can still remember the few feeling my mother’s face every time I would struggle to draw breath. And I remember the relief in her face and how I felt when our family doctor came over to give me a breathing treatment. And so you kind of learn quite a bit about the healing nature of medicine the empathy that that in books and in the practitioner but also the patients and you kind of get a better understanding of what it’s like to lay fear in people as a as a health care practitioner and so my family doctor is I call him Uncle Clarence. You know that really my uncle. But I I I saw him so many times over the course of my childhood that I see certain family for me now. And he was like My initial inspiration to getting to a healing process. So to speak.
Justin: [05:01] Wow wow that is incredible. That really hits close to home. So I’m sure are you asthmatic as well. I’m sorry. No I’m not. But just seeing that the intimate impact that a physician had in your life very early on it’s that that makes perfect sense that it’s kind of what drew you to the field.
Dr. Marshall: [05:18] Yeah. And as you you know like now that I’m a doctor I think I can’t forget how impactful that interaction was. So it’s you know we’re really busy as professionals and it’s hard to kind of find time to reply to that email or enter the phone when someone which is out next to our advice or or for separate tips along the way. And and just the simplest interaction can be so meaningful and impactful for an aspiring doctor that I’m not great at it but I think about it enough to like hit reply and answer the phone when I get those calls sometimes.
Justin: [05:54] Yeah that makes perfect sense. So tell us a little bit about how you transition from being your very competitive you know young man to moving to med school and eventually to an MBA.
Dr. Marshall: [06:07] Sure. So I entered medical school in 2006 and I was probably the most formative time of the portable Care Act and I knew that I did not understand health care economics well enough. And with all the debate and discussion around consolidation in health care payer systems accessibility for patients and and the plethora of nuanced challenges that comes with this healthcare organism I wanted to get some more some more formal training around it. And so I opted to do the M.D. MBA program. It wasn’t a formal program at Emory. It was I took a year off and went to business school and then came back to med school after that. And I’ll tell you that it was probably the most transformational educational experience that I had in the 14 years of schooling that I’ve had to date. Wow. It just change the lens through which I saw the world.
Dr. Marshall: [07:06] It changed the kinds of things I read in my free time it changed the podcast that I listened to now. It helped me create my personal narrative and I can better articulate why I wanted to be a doctor why I want to aspire to do whatever it is that I’m doing because of that kind of thoughtful leadership that might be school professors kind of trained me to articulate. So you learn how to do an elevator pitch and kind of just organize your thoughts about your career your skills your weaknesses and how to mitigate those weaknesses as best as you can. So I think if anyone’s thinking about it from the forget about the economics because there’s there’s the opportunity cost of income if you take time off from med school to go to business school etc. But in terms of just the purely pedagogical content of sitting in a business school classroom it’s unlike anything we do in medicine the hierarchy of being on the wards and you doing the short coat and then there’s 50 years of of folks that are above you in business school it’s your clients like that that schools representing a brand that you have to then graduate and represent them well and so they’re always very cognizant of the fact that there’s something that you’re there to get out of that educational experience.
Dr. Marshall: [08:22] And and I tell you a sweater at Emory they were very good at making sure I got what I need to get out of it.
Justin: [08:28] That’s excellent. Are there as you look back at your business school experience. Are there any transformational either like a class or a book or a principal that you go back to and you think I use this all the time and this is something that if there was one thing that I could command to other positions like get this this principal on lockdown.
Dr. Marshall: [08:44] Sure. I think organizational management and change management. Rick Gilkey was my professor you wrote me a a recommendation letter off to medical school residency. I’m sorry. It’s the kind of course that helps you to appreciate that soft skills become hard skills at some point in time where I became more in tune with the fact that I’m an actual true introvert. I can pretend in short bursts with people that I like but I’m discharged whenever I interact from more than maybe 15 or 20 minutes. And so knowing that I can manage you know how I how I handle meetings and how I market now for my practice I have to do lots of dinners every week with referring physicians. And so I can I’ve learned tricks to kind of mitigate my truly introverted nature.
Justin: [09:36] Got it makes sense. Yeah I guess so I’m coming at this obviously from the other side so I look at medicine as somebody who came up through the business channel and I’m I’m fascinated always by the just understanding economic relationships and the phrase that I go back to is follow the money. Like do you want to understand the incentive of your person or an institution or a system like how do they get paid. How do they make more. That’s what they’re being incented incentivized to do. And that principle alone. For me I find this like if I come into a sort of a situation I don’t understand kind of what’s going on it’s like how how are the economic exchanges economic dynamics happening here. And I find that principle similarly to be very important for young physicians.
Dr. Marshall: [10:17] I couldn’t agree with you more. I think that we don’t discuss economics and medicine enough because there’s you know you worry about the perverse incentives right up of doctors behaving badly because of a financial motivation. I think that under the other side of it is the commoditization of of medicine where we become spokes in a wheel and there’s there’s no reward for productivity and for for corporate innovation so to speak. And so there’s this delicate balance. But having the conversation around incentives and and how are doctors compensated. How are health systems compensated. How do insurers make money and the payers. I think it’s this very complex dynamic that’s interwoven. And if you understand it you are you tend to come out of it better if you don’t you’re doing the menu.
Justin: [11:09] That’s right. That’s right. And honestly I look at the physicians that I know and I see some of the most idealistic and moral and giving and ethical people that I’ve ever met. And I I always think like these are the people that we want empowered with this information to be making decisions to be building the systems. If we if we if not careful to bring that as much education and as much like encouragement and empowerment equipping as possible. I’m I’m a little concerned who’s going to be steering the ship.
Dr. Marshall: [11:38] Sure yeah. So so what. When the suits kind of determine health care policy there’s there’s a challenge right. But I think that a part of this kind of ethos in medicine of being purely altruistic and wanting to be divorced from the finances it’s been a hamstring for many of us. And I’ll tell you that as as as we interview as I interview applicants that I want to start a paying job in private practice there’s a surprisingly high number that that that seems afraid to discuss compensation. Usually female but there it’s this kind of a dirty thing where they prefer to ask about vacation time compared to negotiating on an on the incentives like base salary tract a partnership partnership buying cetera. And so it’s been to the betterment of the system and until like organizations that we’re afraid to discuss the finances around health care.
Justin: [12:36] Yeah and that’s why I’m always going to be beating this drum of like breaking down the walls of it doesn’t need to be scary. You can. You can’t do this if you’re smart enough to go through med school and this stuff is really easy actually sharing able to really grab a hold of it and make it work for you. It’s so powerful and we’ll pay you dividends your entire life. Right.
Dr. Marshall: [12:53] And it’s fun right now. It’s made you want to be in control of your own fate and destiny and you really worked incredibly hard for for you know a decade or more and you wanted to kind of know be able to determine what’s next and what is your path to career prosperity not just in the practice of medicine but in how you take care of your families and getting independent from the debt that you likely incurred while you were in school.
Justin: [13:19] That’s right. So let’s transition now is one day and tell us a little bit about your current practice and the clinical responsibilities you have as director of outcomes and what does that mean and you talked about like doing dinners to to build the business of your pain practice I’m really interested to hear how that’s going.
Dr. Marshall: [13:34] So I’m at Alliance in pain. It’s a large interventional pain practice and the value of our size is that we can actually offer a comprehensive pain management by doing that the non revenue generating things that just makes good medicine right. So we focus on educating our patients on exactly what their disease pathology is we employ a wide range of treatment tools that includes pain psychology physical therapy up with therapy spine interventions and medications when needed. So a part of what I have helped to do is to carefully unintentionally track how we prescribe opioids. What are the patterns across the practice. How do we risk stratify patients that are appropriate for opioid therapy the ones that are not. I think that a large part of what we also have to do is demonstrate value to the system by showing how effective our procedures are. Right. So if we’re going to do a series of epidurals and someone willing to make sure that they actually get the relief that they were open and get out of it and that if they don’t we know what the next step will be that one of the large consumers of health care dollars within the pain space it’s back surgery.
Dr. Marshall: [14:38] Right. And and we see so many folks come out of surgery with persistent pain and disability and so the goal is to get them to get away from the knife and resume some kind of functional mobility and activity. And so that’s a part of what I think about on a day to day basis. My job though I’m I’m clinical five days a week so I’m in the office around 8:00 in the morning. I see I do procedures from 8:00 to roughly 12:00 thirty one o’clock and then I see clinic patients from one o’clock until about 4:00 p.m. once to twice a week I’ll drive out to meet with referring practice. And this is one of the skills that I did not learn in residency and fellowship. This is more of a school thing in that one of the challenges of growing a business and in a medical business is understanding how to speak to the audiences.
Dr. Marshall: [15:32] And we were we’ve got multiple audiences here. The more challenging one is speaking to peers who are professionals themselves. But you do not want to seem condescending. You want to be appreciative of their referral. You may know that a dynamic in which you’re sending your patients to someone else and you want to be respectful of that while you demonstrate value to them. And kind of steer them to to give you a try. So the communication lines of being able to to educate them on exactly what you do and how well you do it is tremendously important. On the flip side being able to communicate to pay in a matter that’s the mayor. That’s reassuring. It’s educating but also you’re not doing medical speak too much. In the age of social media being so rampant and google reviews it just takes a couple really engage patients to to say something about you and stymieing your growth and so on. So it’s it’s it’s a lot of that kind of shaking hands and kissing babies. That’s that’s important to grow into practice.
Justin: [16:34] Yeah. So tell me a little bit maybe you do a case study unlike this is a prank. Maybe it’s like a family practice doc or whoever the referring physicians are ortho who who would be interested in sending you business take me to your strategy like how do I figure out what they want. How do I communicate that to them in a way that they’re going to receive and then that’s going to translate into a reciprocally beneficial arrangement.
Dr. Marshall: [16:55] Sure. So I think the referral that I covered the most are from from spine surgeons. Right. So simply because we worked so well together in the symbiosis of it for a spine surgeon to be able to do that back surgery the patient must have first exhausted conservative measures. And that’s where I come in. So I’m the conservative measures part if I do my job well. The trick here is that the surgeon will not get the business from me. However the point of this system though is to ensure that the right patient get undergo surgery because he or she surgeon does not want to operate on someone who is going to have a poor outcome because they had and the conservative things. So my calculation is ok I first go into the meeting knowing where they send their referrals currently and if I’m getting a false name and if it’s a it was a new referral source I am I’ve prepped where they went to school I’m looking to find common interests and or some commonality in training if they went to Emory like I did I’ll mention that I went to Emory to try and get them shaking their head and smiling at me and then maybe name drop a professor or two that we can have some common ground make a joke about them to get some some kind of art to get them relaxed around me then I I’m proud of where I trained.
Dr. Marshall: [18:10] I’m proud that I went to Harvard and Emory but I mean I’m in Georgia and I’m in. I’m in suburban a little rural Georgia sometimes and it can be off putting if I come in as the Harvard guy that pretends to know more than than the community doctors there. And so a part of the delicate dance is is is playing up to what I know they need to hear from me which is that I am well-trained and board certified and I’ll be able to treat their patients with caring and compassion that I’ll get my notes back to them in in a quick expeditious manner. And I have open communication lines. But then the biggest thing would be access to my schedule.
Dr. Marshall: [18:53] So if they send me a referral I will personally get them in within a week. If I if you can say that it helps that physician because as they’re sitting with the patient that needs to be seen they don’t want to have to wait for them to wait for three months for their next specialist appointment.
Dr. Marshall: [19:09] And so I’ll often leave my cell phone. I encourage them to text me.
Dr. Marshall: [19:12] And that kind of moves the scale to being a more accessible doctor for him. I often say look if you have a curb side that you want to just ask me a text GIVE ME A CALL. No need to send a referral over. I’m happy to kind of guide you through how to prescribe the prescribed medication to someone and tell you what’s safe and what’s not safe. And I’ve found that that that strategy is quite helpful.
Justin: [19:34] Most of the time makes sense. So I’m sure there’s people out there listening young pain docs who are a year or two into a practice and I think this is brilliant. I would love to be able to add value to my practice by building these referral relationships bringing in new patients. How the heck do you get a meeting like because this is something that is definitely not covered in residency. Sure. Are you cold calling you’re not going indoors. You show up with donuts on a Monday. Yeah. Social media. What are you doing to get in front of these spine surgeons.
Dr. Marshall: [20:01] So at the gatekeepers the receptionist you’ve got to be nice to them.
Dr. Marshall: [20:04] So in my practice I have I have a marketing rep who will go out with with donuts the paper Chick Fillet lunches and he’ll just butter up the front desk folks and get them to let us know when that doctor’s calendar is open for us to be there for breakfast or a lunchtime meeting. The other thing would be just trying to find a way to meet them where they are. So they’d be going to the conferences that you know like the spying conferences for surgeons. I’ll go to those conferences and meetings as well locally to be able interact with the surgeons. They’re
Justin: [20:35] awesome. That makes perfect sense. And you mentioned one other thing and I want to touch on before we move on and it’s the social element with like the you know patients leaving reviews on Google or like managing like somebody now can like to you on Twitter and say hey at you know doctors one day like why weren’t you there when it came to my appointment yesterday. You know what. I just put you on blast and there’s never been this degree of transparency or giving a huge platform to potentially like disparate and you know it’s only going to be that like three percent of people or is like just that person. I mean in many cases I should say who’s who’s going to give you the bad publicity where maybe if you do a great job for 95 percent of folks they don’t leave you a five star review. So how do you manage this in your practice to be able to do damage control be like receptive and be compassionate but not you know just deal with all of that. It’s a very volatile potential situation.
Dr. Marshall: [21:29] It’s tough and it’s really tough for pain because incentives are not always aligned right. What that patient came in expecting to get may not be the best thing for them and I might be the person that Tom that they can’t get what they wanted. That’s oftentimes Percocet. Right. And so. So it’s not uncommon for a patient to leave a pain practice disgruntled and angry. But the advice that they received was the best advice for them for society for a health care system. And so there is a level of of sitting down and talking slowly and explaining why the risks outweigh the benefit for it for it. There for one therapy the other and then you just gotta pray that don’t they don’t get angry enough to go ahead and leave a bad review about you because once they’re out there you’re kind of stuck with having to respond.
Dr. Marshall: [22:17] And I haven’t quite figured if I should be responding to the bad reviews or if you kind of stay quiet about it and hope there’s enough good ones to come afterwards. But of course you’ll have your all stars you know the folks that that bring you cookies and doughnuts because you’re so happy about your service and you’ll ask in person to write reviews as well. And hopefully it balances out where it’s only about 3 percent bad and 97 percent. But it’s certainly a challenge especially in the pain space. I mentioned Percocet where we’re in the front lines of this opioid crisis. This is a uniquely American problem like it is the number one prescribed medication for maybe 16 years running. Number two is not know that statistic that’s in it. Oh yeah life’s Interpol’s number to send twice. Number three the US is 5 percent of the world population.
Dr. Marshall: [23:06] Four point eight percent we consume eighty seven percent of all oxycodone. Ninety nine percent of all hydrocodone. So oh yeah. In the time we had this chat there’s going to be two overdose deaths. So the data is staggering. And we’re in the front line of this epidemic. There’s this responsibility of making sure that that you treat people with compassion empathy and fairness. But also knowing the kind of social context of narcotics in every script that you prescribe as a script that could potentially be misused abused or diverted. And so there’s that element to things as well.
Justin: [23:44] Yeah. And I know one of the things when we discussed earlier one of the ways that you use your expertise in the opioid conversation specifically is in the expert witness and capacity to weigh in clinically on whether or not a procedure is appropriate and you can you talk a little bit about the dynamics of what it means to be an expert witness what it means to be able to make those types of assessments and what is the context for that that to happen.
Dr. Marshall: [24:09] Sure. So I think I was a little intentional about expert witness rep when I was in fellowship. I had to have a great mentor. He still is a mentor of mine Jason Young at Brigham and Women’s.
Dr. Marshall: [24:21] And I know he was an expert work and I figured that I need to kind of carve out something I knew a lot about and it could be you in drug screens it could be a particular procedure spinal cord stimulation. Mine was opioid data right so I did a Grand Rounds presentation and fellowship on the opioid crisis and the numbers I quoted you just now I researched them and I kind of kept track over the course of the last four years since I left Boston and began to give talks locally on opioids and the crisis and how to appropriately prescribe and avoid prosecution. So I was hosting with treats for hospital systems to speak with primary care doctors about prescribing practices et cetera and what my first time doing it. The feds called me. So the U.S. attorney office saw my profile on our website and maybe saw that I’d been giving talks on the topic and reached out and what it means is I’m gonna be a subject matter expert in the sense of as their beginning put together a case with this prosecution or defense they need to to better understand the context of medicine where are the details around what most physicians will do what are the bounds of usual practice and help them to understand how far outside the bounds a physician is or how to defend someone who’s accused of being outside the bounds and say that this is actually one of the exception cases that’s allowed to have this unusual appearing prescription.
Dr. Marshall: [25:52] But it’s it’s actually within within the context of a good medicine. So it’s it’s a relatively lucrative ancillary income. I’ll give you some hard numbers since I think your listeners would care to know I charged between five and hundred dollars an hour. If if if a case goes to trial you actually get between twenty five and forty five hours of work and that includes reviewing case files summarizing a report that details the elements that are concerning and then being prepared to go testify in court. Understand and kind of face the the the opposing counsel and their challenges to whatever your opinion is. So having being ready to buy that kind of debate is also a good skill to have.
Justin: [26:38] Yeah.
Dr. Marshall: [26:39] You take me to the moment of your first cross-examination so I’ll tell you this I have not had to be cross-examined. They are I’ve done I’ve been several these cases but it ends up being a battle of the penmanship. Right. So their expert submits a report I submit a report and then depending on how compelling the report is. And the overall case will be there will be to settle outside of court and so on. So. So it’s sometimes the is like what are your credentials. Whose expert is better you know who’s more credible on this topic. And so I’ve had to write reports to kind of establish my credibility and also poke holes in the opposing opinion both because of the maybe the practice that that that experts coming from the the location and the patient population that that experts used to and seeing why it’s not a good fit for the case that we’re looking at currently. I’ll likely be in court in January though and in two months this case is certainly going to go to trial and I’m getting ready for that. OK.
Justin: [27:41] That’s. So have you done. Have you been in court before. I have. Yes.
Dr. Marshall: [27:45] Yes. And you know I think there’s this I think society in general still has a whole lot of respect for doctors and so usually folks kind of like prepare you for the year about a stabbing. So you know their whole of it’s like Doc in your opinion and you know we know this is you know this may sound odd but do you think it’s never really aggressive.
Dr. Marshall: [28:11] And the circles are small. So I may be on the prosecution side in this case and then that defense counsel may hire me for a defense case three months later. So. So it’s not as acrimonious as it sounds.
Justin: [28:26] OK. So for somebody out there who thinks you know what I’m really intrigued by the idea of expert witnesses obviously one day for you you’ve you did all the research you were doing the talks and then the opportunities found you. What about somebody who’s interested in branching out. They like the idea of ancillary income they like the idea of being an expert. Being in the courtroom going through all of that. How would somebody how would you recommend somebody go about finding an opportunity like that.
Dr. Marshall: [28:48] Yeah I think networking with slick lawyers would be the easiest place to begin with the workers compensation boards with them with disability practices the docs that do disability ratings and impairments for it for employees who have any kind of health challenge. Often they’ll need to have a physician do an independent medical evaluation. It’s a start to get into an expert role where you’ll you’ll do it you’ll provide an unbiased opinion of their health care kind of advice over the course of some period of time and you’ll render an objective opinion and that’s that gets your name up there in the physician circles and the legal circles sorry. And then with that you can kind of parlay into being an expert on a bigger case.
Justin: [29:36] OK can you maybe give us one or two examples of a case you’ve worked on recently and sort of whether it was for prosecution or defense and how you interacted with it and what the verdict was.
Dr. Marshall: [29:46] Sure. So George is in the hot seat for opioids and the epidemic. And we had a doctor in Savannah Georgia a family medicine doctor. He was the number one prescribe oxycontin on the in the southeast in the southeast. And he routinely prescribed OxyContin Percocet Xanax and Soma in combination.
Dr. Marshall: [30:10] He prescribed the highest dose of each medication to the patients which means that there is a street value component to what he’s giving them. Patients traveled great distances to see him. He charged cash for scripts. It was absolutely egregious and easy for me to agree to be an expert on the on the prosecution side of this case. I thought that it was going to be hard for them to find an expert in the defense side to defend his actions. And it was hard. He didn’t have an expert submit a defense. And I thought it was going to be a deal where he was going to not go to a full trial. The challenge for him was that he was older and if he if he settled for it they may have offered him maybe a 10 years in prison.
Dr. Marshall: [30:57] And by that he would probably die in jail and so he had no choice but to go ahead and go to go to trial. And he was convicted earlier this month of an I think twelve counts of prescribing recklessly and so so. So he hasn’t had the sentencing part yet. Now I mentioned that he was number one prescriber and that case was a little bit easier to kind of see the folly in where things went awry.
Dr. Marshall: [31:24] But I made the mistake of telling you that he was the number one prescriber as if that matters. Right. Because on the other side you have a lot of doctors who were being prosecuted because of big data. OK. What does it mean to be the number one prescriber. Well someone has to be number one. And does that necessarily portend bad behavior. It does not. And what kind of practice is that. Where is that doctor. Are they seeing a lot of oncology patients are there. Is there access to pain practices within twenty five square miles of doctors practicing and so I’ve been on the other side of a defense case in which I thought that the the the the position of this case was not benefiting financially from the scripts she was running a small family medicine office where about 13 percent of our patients were getting pain medications principally because there were a lot of prosecutions of pain practices within a 10 square mile radius and those got shut down.
Dr. Marshall: [32:30] So you’ve got an influx of which is coming in saying hey doc I know you do my hypertension but I need my purpose X as well. She was the only provider for Medicaid services within a 50 square mile radius. And with Medicaid they don’t pay for physical therapy. They don’t pay for MRI. You can’t do the usual and customary workup to diagnose things the way you would if you if you’re in a well resourced area. And so the red flags in her case can be explained if you look at the circumstances and yet and yet I think it is the kind of case where the board the medical board and and in her tone did not take away her license. They they they gave her. But she got to get educated better not opioid prescribing complete some semi’s and they limited the amount of opioids she could prescribe but she still can prescribe.
Dr. Marshall: [33:23] But yet the U.S. attorneys there are going after her for a criminal prosecution with jail time. And so I think that’s unfortunate there. So this is a to understand this this problem you have to hold two opposing views in your head at the same time and figure out the nuance of it. This is a real epidemic people are dying every hour. And as as a pain provider you go in the front line of giving access to these controlled substances. On the other hand there cannot be an overreliance on big data when this is a nuanced issue. Right. And so when so when when the papers report that this doctor prescribed you know thirty two thousand milligrams of oxycodone what does that actually mean. I mean they’re seeing their patients a day five days a week for six months. That’s not a big number. OK. So you can sensationalize headlines and totally miss the fact that these are that that there’s doctors try to just do right by patients and they get caught up in the crossfire.
Justin: [34:30] That makes perfect sense. Thanks for sharing that one day. You’re welcome. So I want to wrap up with the topic that initially connected us and I’m really interested to hear about Dr. Doc that’s DRC number two DRC which is your physician lending endeavor. So tell us about the genesis of this idea and how things are going and what it’s all about. Sure.
Dr. Marshall: [34:51] So I’m happy to do it. Thank you for the opportunity. So when I moved from Emory to go to Boston for our residency I needed to to get fourteen thousand dollars. It was first last month’s rent deposit as well and I didn’t have a single parent homes as you know and just didn’t have 14 grand laying around. So I need to borrow the money.
Dr. Marshall: [35:11] Well I also had above average student loan debt. I had a final score that was sub 700 and the banks look at my profile and I look high risk and paper to them. And so the rate that I was given for that loan was north of 15 percent. Yeah. And so about 12 percent of my peers borrow money for transition. Now there’s a much larger proportion of us that’ll swipe our credit cards during residency and fellowship as life happens. Right. You know there’s the birth of kids. You’re making a modest income working a lot of long hours but you just are not making enough money to make ends meet sometimes and so you leverage debt to kind of live and and and because of the way the traditional credit system is set up we’re penalized for it for the toll that that it takes to kind of become a doctor while in training.
Dr. Marshall: [36:06] My co-founder came Allen and I met at Brigham and Women’s and we had a very similar experience to mine and we decided to pull a funding together with physician investors that would underwrite risk for doctors prospectively instead of relying solely on psycho school and debt to income ratios. We cared more about where you’re headed in your career to at your specialty where you went to school. Any honors in medical school that you achieved. If you’re a medical student with your board scores where you want to predict you practicing medicine and staying in medicine and using that to get our interest rates lower than the marketplace we’ve been quite successful in doing that to date.
Dr. Marshall: [36:49] Repeating so fine earnest by about one hundred eighty basis points on average. We’ve deployed about half a million dollars to date in loans since we started giving out loans twelve weeks ago and our borrower experiences is good. Borrowers speak to a doctor when they where they contact us and we’re able to kind of walk them through how to borrow when not to borrow will advise folks not to take out debt if they don’t have to take up the debt and then we charge no prepayment penalties because we expect that they’re going to be earning more at some finite period of time in the future and so they can zero or they’d get out without any prepayment penalties from us. And so it’s it’s been quick to kind of create this ecosystem of doctors helping doctors and we’re really proud of it and some of the some some of the most fun I’ve had in the last twelve weeks has been kind of hearing the borrower stories of why they want me to borrow money it’s heart wrenching and it’s also just really fun to understand the human condition and what doctors go through to actually get to where they need to be totally.
Justin: [37:54] And I love this theme for you of using a nuanced perspective to take what has previously been handled poorly by big data and saying if we are prospective rather than retrospective which is exactly what you just described for the opioid situation then we can determine that well actually the cohort of people who graduated from medical school and matched to an anaesthesia residency across the country like of course they made no money. And of course they have it and not that great credit score. But if you add another layer of filtering you can see like these are the among the lowest credit risk people probably all of society. They’re actually a pretty good bet in that way.
Dr. Marshall: [38:29] You are way more articulate than I was. And that’s well thought out and perfect.
Justin: [38:33] So tell me about you share sort of coming up with this idea and then sharing the idea with a couple of friends and getting investors. How did that process go for you.
Dr. Marshall: [38:41] Yeah so. So Quentin and I kind of talked about it for some time and then this is a highly regulated industry so it’s banking it’s money it’s lending. And so to get to the point where we can actually give loans you need to get a state by state lending process. Well we pitched our idea to go to a bank out of Wisconsin. I spoke to their board and they decide to pick us up which gets us a bank that’s behind origination of our loan. So it’s our funds but we get access to all 50 states. Right. And so we were able to cement that deal after 12 months after we initially got the yes from them with all the legal diligence etc..
Dr. Marshall: [39:21] And the other part of this was getting our friends mentors and faculty members to stress test the idea. So we actually pitched the first iteration of the concept at the GSA two years ago to a cohort of anesthesiologists like we had small like kind of shark tank sessions set up where they were there where is our team and six to seven anesthesiologists that we surveyed want to kind of run a concept by you guys look for a blind spots tell us what’s missing what are we not seeing here. And we came out of that pit session looking for ideas and kind of thoughtfulness around how to make this a real business with offers for investment and and that’s how we knew we were onto something real. And then from there the word kind of spread. It’s good to have rich friends we’re where we’re in a profession in which there’s a lot of disposable income and so on. So a lot of our friends who who believe in the concept and believe in helping helping peers wrote those checks.
Justin: [40:21] Awesome. So for anybody listening out there anaesthesia success dot com slash 33 we’re going to link to all this good information in the show notes we’re going to link to Dr. doc. And so what do you maybe tell us a little bit about a typical borrower profile for some of the money that you’ve lent thus far are you finding that they all kind of look the same or there’s a couple of specific situations where you can really most impactful engage.
Dr. Marshall: [40:43] Oh they don’t click the same at all. It’s so varied and wide let me tell you we learned from fourth year medical students who’ve matched to in practice physicians thus far most of our barbers have been in practice physicians. And it can be for reasons like there are 10 any nine contractor I got hit with a tax bill that I didn’t expect. And so they’re having to kind of get the tax bill taken care up for our in training positions. There’s been quite a bit of relocation costs like you know we had a board out of out of New York who needed to move to California and needed to cover our expenses over the course of the conversation. We figured out that she was taking our board exams pretty soon after she moved to California and after we gave her the loan she got a board prep packet adoptive parents just to say I thank you for the business.
Dr. Marshall: [41:33] And we’re looking out for you but there forward was the one kind of exotic forward that we’ve had is someone who came in to borrow for for cryo egg preservation cryo preservation because early in a neurosurgery residency will graduate several several years from now and wanted to preserve fertility and the cost of freezing eggs is extraordinarily expensive it’s above thirty thousand dollars and that’s important to her and her family and so. So we’re issued with a loan for that as well. So it runs the gamut and there’s a level of shame that I’m seeing for doctors that apply for our loans and it’s been applying secret right. And part of what we’re trying to do is to destigmatize the need. It’s it’s not good to borrow unnecessarily but when there is a need to cover life’s expenses I think it’s you know it’s one of the things where we have to be supportive of our of our peers in that sense and so it’s a confidential process but we want to ensure that folks know that there are others that have lived through it. I personally have them on the other side of it now and and I will help them get there to WoW.
Justin: [42:45] That is incredible. So what are the what are your goals for the business what would you like to see happen with it in the next couple of year. I mean it seems like the sky’s the limit. I know personally so many people who I’m like maybe this.
Dr. Marshall: [42:58] Sure. So. So we have a number of relationships with different schools and programs we’re talking to to financial advisors at medical schools and also to some of both wealth wealth managers as well. And we’re seeing a lot of folks with credit high credit card debt at the 20s interest rate payers and we’re able to repay those goals. So I think what we’d like to do is give access to any doctor who needs to access capital that should do so at a fair rate and by a fair way should be competitive because I don’t want to see it continue to be penalized for the time it takes to become a physician interest noble profession. We’re a tough population to feel sorry for and we’re not looking for sympathy you know. But I think it’s it’s lost in folks the kind of toll it takes not just on your life but but on your financial health. And if and if you have a family it’s even more challenging. And so we’re going to be supportive I think as the company grows you want to be able to to to help empower doctors to understand more about contract said and student loan refinancing.
Dr. Marshall: [44:09] We wanna be able to to point missions internationally. My co-founder spent a lot of time in Africa with his wife doing a medical mission where I travel once a year for a lot of our a lot of our team. They’re highly motivated about getting care to disadvantage parts of the world. That’s a large part of what motivates us as well. Awesome.
Justin: [44:29] That’s such an exciting vision. I can’t wait to see how you guys continue to grow and thrive in the future hopefully. Thank you Justin. So thank you for your time. One day I want to close it up with this last question. You’re a very accomplished physician entrepreneur you’ve got a lot going on. You’re doing a lot of great work. I’m curious as you look at all the things you’re doing maybe zoom in on one experience or one endeavor that you are really proud of and take us to that moment when you kind of have this realization of what I’m doing right now the work that I’m doing whether it’s with the patient or with it. You talk to that one borrower who is like crying on the phone thanking you for that like taking that moment when you said you know what. I’m really proud of this. I’m so glad I’m doing it. And this has all been worth it.
Dr. Marshall: [45:11] Tough question. It’s not some question that I have to reflect on the many times I’ve felt good about what I’m doing. It happens often. I’m in a profession in which you get to impact lives a lot and it’s not often that you have to look up and think about this as being an impactful experience. I’ll tell you. So I thought through this a little and I was in Boston doing the Boston Marathon bombings and I was a part of the care team at Brigham for that and that was incredible from from from a clinician perspective of being able to see the kind of hope that folks that were losing limbs still had for for their life’s outcome. Right. I was also there when a physician was shot in the hospital and he was a beloved doctor who had done residency there done did medical school there and UN staff there.
Dr. Marshall: [46:01] And then we cared for him in his final hours. And he did pass away. And so being a part of that experience and thinking about you know the the human condition and fragility of life and what we do was was was incredible. And I was that’s a bit of a dark example to the question but in my I think in my day job I had a patient who was a pastor and had a car accident and crushed both of his legs in the accident and had several surgeries in the legs to kind of get that to regain the ability to walk and stand and he can stand and walk but you just couldn’t stand at the pulpit for an hour sermon. Right. He ended up coming to see me and we did a procedure for him. It’s called a spinal cord stimulator kind of a pacemaker for the spine.
Dr. Marshall: [46:51] And I remember that. We got his insurance to approve the procedure close to the end of a year and that it was going to expire within days. And so we had to get it done before January 1 of the following year. And it may admit that my staff had to stay late that evening. So it came late. Still people tend to be grumpy at four four thirty when you start a case of that time. It’s not it’s not fun. And the case went well when he woke up and his wife and son were there to get him and said No it’s not nighttime.
Dr. Marshall: [47:24] And he stood up and turned the stimulator on and started to cry and his wife started to cry and he started thanking me and thanked the staff that were there and everyone started crying.
Dr. Marshall: [47:36] This it’s around Christmas time. And and I left there like thinking to myself like if every experience was like this like it’s it I was so moved that I had goose bumps as it happened and I think about it now I still remember his face and and his wife’s face and the experience of feeling as though I had a meaningful interaction is going to improve this guy’s quality of life for not just him but for his wife and their two kids.
Dr. Marshall: [48:03] And I see him now every year once a year and he brings a cake for me from his latest trip for his for his Miss ministerial travel. And it’s it’s it’s one of the most impactful speeches I’ve had.
Justin: [48:18] That is incredible. I’m getting a little misty here just his story. I can’t I can’t imagine just being there must have been really special. It was incredible. Well thank you very much for sharing that story. And doctors why they Marshall. Thank you for joining us today on the anesthesia success podcast.
Justin: [48:34] Thank you so much.
Dr. Marshall: [48:34] Justin it’s a pleasure to be here.