Topics Discussed Include the Following...

*PRP for Back Pain
*PRP for Tennis Elbow
*The Magic of 1,000 Fans (and the criteria that make 1 million a year)

Video/Recording of CMA Journal Club, Pearl Exchange, & Marketing Tips

Transcript, Relevant Research, Relevant Links

Transcript

JCPM2023.05.30\

Charles Runels, MD:

Welcome to the Journal Club. Those of you who've been win our group for more than a year have heard me talk about this article, 1,000 True Fans. It's a true classic in the internet world. Tim Ferris featured an edited version of this in one of his books.

The essay went viral for the first time in 2008. It's one of the things that I try to read at least once a year just to remind myself of some basic principles. So we'll go over this and how I think it might actually be very encouraging to your practice, especially those of you who are trying to make the move from an insurance-based practice to an all-cash practice. I just wanted to run some numbers by you that I think will shock you and encourage you.

But before we do this, a couple of papers. I don't think we'll be on for the whole hour tonight unless you guys have questions. A couple of papers that have been helpful.

PRP is better than steroids for back pain

First one is one that hit my blind spot regarding a question that I get frequently, has to do with back pain. And I put both of these articles in the downloadable version. If you look, if you click on the little orange button and pop it up and download it before we close the thing out, you'll have it. This one is regarding the effect of PRP for low back pain.

For a control, they used steroids and they had people rate their pain. And you'll see a common theme here. I didn't know this had been studied to the extent it has, but if you look at the references here, not too shabby. A number of papers use basically an epidural like you would with steroids.

And this is the picture I wanted to show you: In the beginning, the steroids look great and then they fall off where the platelet-rich plasma falls off faster. So if you're looking at a week or two out, the people who got steroids are doing better. They have less pain than the ones who got PRP.

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But then if you follow them for six months, those who got the PRP do better. Much better!

PRP is better than steroids for tennis elbow

Now, if you go flip over here to this one, this one has to do with tennis elbow, and they showed the same thing. In the beginning ... Both of these are out within the past month. I mean, if you just go to PubMed, every week, there's at least 20 significant papers out, just logarithmic growth of this, of the research regarding regenerative therapies.

Let me just show you this so you see where I come up with some of this. It's so easy because there's so much to choose from. Let me just show you. We'll come back to this paper. Won't belabor it, but I want to show you something. So if you go to PubMed and you just put in platelet-rich plasma and you look at what's come out over the years, well, let me go back to this beginning. You see this starting about 1954 and then it just shoots up, and it looks like maybe the past year or two might have leveled off some because 2022 looks like it was about like 2021. But lots of papers and when I flip through it, a lot of it is redundant. For example, this one, how many times do we need to show that a double spin makes more platelets than a single spin? We know it. Whenever I read that, I think, well, wonderful, but how does that apply to our particular indications? We know you need a certain number of platelets. Lots of research show you need a certain amount for joints.

But we don't have that same knowledge about most of the soft tissue medications we're doing. And I always think, well, we don't have to go spin platelets to heal from surgery. So obviously there's some ideal level or maybe not. Maybe there's just continuing returns as concentrated as you can make it with maybe some minimal effective level that makes it better than just whole blood for each of the different indications. But anyway, I'm not sure. I think maybe the people who did this study just needed more street cred for their centrifuge, so a harvest centrifuge. But how many times you need to show that you can put more platelets in a smaller space and pull out more red cells and white cells if you're doing double spin centrifuge.

So that's how every week when I go through what's out, I'm listening to what we're doing, how does it apply specifically to our indications for our specific trademark procedures, but also what's going on clinically versus what might be shown in the laboratory or even in a study that's not relevant or it's old news. That's where I'm coming up with some of this. And if you look, there are just so many ... There are pages and pages every week to choose from, and I'm somewhat arbitrary, but my hope is that I'm picking the ones that are most helpful.

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So this one caught my eye this week because it's out just in the past month or so, and I have that question a lot. Someone has back pain, they wanted to know, well, what can I do?

We have radiologists in our group that do that sort of thing, and some are even involved in research with stem cells, but honestly, I have lots of blind spots and this was one of them. I didn't have a lot of knowledge about this or know that as much had been done. But there seems to be this biphasic thing that goes on or asynchronous thing, I should say, that goes on that I think is with a lot of these studies where they compare steroids. And this is the time, and the slope of the line might vary some, but this is the common theme.

Steroids make you feel good for a week or two, but once you're a month or two out, you're experiencing the benefits of new healthier tissue while the steroids are wearing off and you're just hurt again, and faster joint destruction.

We see that theme played out over and over again, and it's played out in the back as well as tennis elbow.

And I didn't even pull it up, but there was another study out this month showing that multiple injections in the knee worked better than one. I used to wonder if that was really a thing with the hair, if someone finally did this study, or the second to ... if you're doing hair every six weeks times three, maybe you don't need the last two because it would've gotten better without them. But someone finally did that study. We covered it in the Journal Club, and you actually do see a better result if you give multiple treatments separated six to eight weeks apart.

What's the ideal separation with joints?

I think it might be longer than the six weeks in the soft tissue studies. I don't know. But there was a study that came out in the past month showing that three knee injections with PRP work better than one, as you might expect.

Charles Runels, MD:

You're on.

Jeffrey Piccirillo, DO:

So, thanks for inviting me to speak.

The guy in the United States that has done more research on this than anybody is a guy by the name of Kevin Pauza and he is at Texas Spine Institute and he has been doing intradiscal injections now for probably about the last seven or eight years and has been having some really amazing results and looking at MRIs both before and after injection and has been able to increase disc height by several millimeters with PRP injections into the nucleus pulposus . And so I think that reading the study, and I know ... I'm not sure everybody out there knows, but you sent it over to me about an hour before Journal Club and I looked at it, and the one thing I couldn't tell just looking at the abstract, whether they were going intradiscal or they were going into the epidural space, but now looking at it, I think the perfect combination would be to do both at the same setting.

When we had patients that would come in with low back pain and no radicular symptoms, so no nerve symptoms going down the leg, usually the pain generator was the disc. And so if you could do something ...

We were doing ablations of the facet joints and things like that, but if you could treat the discogenic pain, then you could get this pain to go away. And a lot of times, that was really hard to treat.

They were using intrathecal morphine and things like that to try to treat that pain through a pain pump.

But now with PRP, I think we have the perfect opportunity. We can put PRP into the disc. We can put PRP into the epidural space and that way, we treat both the exterior of the disc and the interior of the disc at the same time and we can get rid of that pain generator. One of the biggest problems in orthopedics was what do you do with somebody with low back pain with no radicular symptoms? And there's not a great answer.

Spine fusion often is where the surgeons go, but those are fraught with all kind of havoc and bad outcomes. And so I think this is a great option.

Charles Runels, MD:

Yeah, I'm still not sure where you go to have it done. I have my favorite radiologist in our group that I send people to. But I ...

Jeffrey Piccirillo, DO:

Yeah, probably the biggest guy is Kevin Pauza, P-A-U-Z-A in Tyler, Texas. He's probably done more than anyone else.

Charles Runels, MD:

All right. Great. Great tip. Maybe we can get him on the call sometime.

Marina asked, any studies to show PRP helping with trigeminal neuralgia? We actually had someone one of our classes recently that we injected hoping it might be of help, and I don't have feedback. I've looked for research in that regard and I haven't found much.

One study done in Poland that is in Polish that just clustered it the numbers in with headaches other than migraine. So that's definitely an area of someone wanting to do a study. We don't have it. inaudible 00:12:39-

Jeffrey Piccirillo, DO:

There are some studies out, Charles that show injecting the facial nerve for Bell's palsy does bring nerve function back faster. So you would think that injecting the trigeminal nerve for trigeminal neuralgia would absolutely work.

Charles Runels, MD:

Yep, that's a great point. I think the last time I counted ... There's three of those. I've treated one person with Bell's palsy. I mean, who knows? It gets well on its own, anyway.

Jeffrey Piccirillo, DO:

Yeah, right.

Charles Runels, MD:

It's one of those where a one-off, you're not sure, but then I've also had a couple of people recover sensation in the face years after some sort of trauma. All right, let me go over this. Thanks for jumping in, Jeffrey Piccirillo, DO. inaudible 00:13:19.

Jeffrey Piccirillo, DO:

Oh, thanks, Charles. Thanks for asking.

The Principle of 1,000 Fans

Charles Runels, MD:

Okay. All right, so the next thing I want to go over is this idea of 1,000 fans.

It's really hard to emphasize. There aren't many things that I've just put on my list to read once a year. Some things you know, but they come out of consciousness and either you get unfocused or you ... I'm saying maybe not you, but I. I become unfocused or think about the wrong thing and become less effective or more discouraged than I should.

So I'm going to put this link and I recommend you go. I'm not going to copy paste it because it's his intellectual property, but I'll put a link to this in the chat box.

Read about the Principle of 1,000 Fans, the Original Article<—

I hope you'll click it and after the call is over, you'll just pull it up and read it, print it out, maybe read it at least once.

Hopefully you'll read it once a year. I'll read to you my favorite parts. I'll do some math that'll take five minutes, and we'll call it a night. All right.

By the way, I met the man who made Taylor Swift famous. When I say ... He didn't make her an amazing performer. I mean, I'm 63. I would love to go see Taylor Swift.

Her last concert I was reading where she did three shows in a row and altogether performed for 250,000 people, that's crazy.

She's the daughter of a physician and he paid a man 250,000, ironically, $250,000 a year and it only took a couple years for this man to do what he could to promote Taylor Swift. And then once she reached a certain level, they turned her over to another agent. But when she was first starting, that's what they did. And when you try to think about becoming a Taylor Swift or a Dr. Miami even in our field, someone who has millions of followers, it can be daunting and you can start thinking that's what you have to do.

But I want to do some math for you right now. I'm just going to get this out of the way. Actually, let's read part of this first. I won't read you the whole thing.

To be a successful creator, you do not need millions.

And I know you guys have probably read this whole page, but I just want to say it out loud. You don't need millions of dollars or millions of customers, millions of clients to make a living as a craftsperson, a photographer, a musician, designer, author, animator, entrepreneur or inventor. You only need thousands of true fans.

Now, most people in private practice ... I'm going to compare this to an internist. Internist might have 3,000 charts, 5,000 charts depending on how long they've been in practice and an internist making 250, we'll just use round numbers, 250 to 500,000 a year, taking that much home. I don't mean gross, I mean taking that much home, is working pretty hard. I think we can all agree. Family practitioner, internist, they're answering the phone a lot, seeing lots of people and they're working pretty hard.

So, let's just kind of get a frame of reference about how many fans you would need on a cash-paying basis to see something like that in your practice. For those of you who are trying to move from the ER or hospitalist or your primary care and your burnout, you want to sell your practice and move to all cash, or you have a busy practice, but you're thinking, "Well, how can I grow it?"

All right, a true fan is defined as a fan that will buy anything you make.

These diehard fans will drive 200 miles to see you sing. They'll buy the hardback and the paperback and the audible version of your book.

They'll buy your next figurine. They'll pay for your best DVD. They'll come to your chef's table once a month.

I read that Gene Simmons put out a book, I think it cost $1,000, some outrageously huge book of just pictures of KISS performing. And he said he personally picked up the checks and took the book and mailed it, but it was a thousand-dollar book, so you don't have to mail too many of those to make it worth walking to the post office.

Anyway, he had those sorts of fans and inaudible 00:18:04

I wasn't a huge KISS fan, but they actually are up in the top five for the most moneymaking band ever.

And he (Gene Simmons) managed his own band towards the end, said he'd never been drunk in his life, never had anything like Kool-Aid up his nose. While all of his bandmates were getting drunk and crashing cars, he was saving his money, and didn't even buy a car until he was 35. His mom was a refugee from a Nazi war camp. He's a very smart, hardworking businessman. Anyway, but they had ... Back to the fan. They had diehard fans.

Now, as you guys know, if you're in medicine, you have diehard fans already, but how could you get a measure for the quantity of diehard fans you need to be able to have a practice that approaches either hardworking, internist, or prospering surgeon?

Two Things Needed to Make it All Work

Okay, here's how the math works. You need to meet two criteria.

Criterion 1: Create or Do Enough Each Year to Collect $1,000 from Each Fan

First, (in this article) you have to create enough each year that you earn an average of $100 profit from each fan. But, with us, that's 1,000. 1,000 to 2,000 profit from each fan is what you're looking for, right? Yeah, it's easier to do in our business than in some.

Now, if you're selling music on iTunes now, it's not too much of a hit to sell one song. It's always easier to give your existing customers more than it is to find new fans.

Criterion 2: You need a direct relationship.

No middleman. You cannot do this with an insurance-based practice.

You must fire the pimp.

With an Insurance practice, you have 2 or 3 middlemen.

And this is why this is so key to cash-based doctors. You cannot live the same lifestyle when you have a middleman.

You actually have two middlemen or three. You have somebody filling out the forms. You have someone who's an expert at collecting the money out of your pimp, the insurance company, and then you have the insurance company.

So you have really three people sharing your payday.

If you have a direct relationship and they're actually paying you, that takes out the middleman.

All right. If you keep the full hundred dollars, then you only need 1,000 then to earn 100,000 per year, and that's a living.

Well, it's a living if you have no overhead. It's a decent living.

And if you multiply ... If you knew how many hours it would take to do that with our practice, you might have some idea, hours of your life, of how long you might need to work to accomplish the same thing.

Again, he makes a big point. This is not an absolute number. It's just to give you a multiplier, a factor to get some level.

A Day’s Wages is All You Need

His thing is the person should be willing to spend a day's worth of their pay, whatever they make per year, a day's worth of it per year on your stuff.

Not a bad guideline.

Would your patient be willing to pay one day's worth of their take-home pay to you per year?

Amazing Math to Change Your Life

All right, so let me do some math for you. Hold on a second. Let me see if I can make this thing inaudible 00:21:43 for you. All right. This is where I hope it gets interesting for you.

All right, imagine we're just going to use a neuromodulator, and we're going to say the person gets $500 worth per treatment. And let's say that you're using Xeomin or Jeuveau where you get a decent markup, and you're going to profit from that, not counting the lights and whoever's helping you. I'm going to get to that part. I'm not going to ignore that part. I'll get to it. But you're going to make somewhere around that much. This is a fairly routine treatment for neuromodulators, and that would be a fairly routine profit.

$500/2 = $250

Treatment every 3 months -> 4 x a year

So, $250 x 4 = $1,000 per year

And they come every three months, so that would be four treatments a year.

So there's your thousand dollars profit per year. Not a hundred; a thousand per year. They haven't done a Vampire Facelift®.

They haven't done a P-Shot®. They haven't done filler or hormones or anything else, just that. N

Now, we can throw in a cream, and we're going to tell you how to think about, or one way you might think about your employees in a moment.

But let's think, well, how much time would that take? Let's decide that you're like me and you like to spend time with your people. I mean, today, I had a Botox patient. I still see people, I don't feel like I have any right teaching anything I'm not doing anymore.

One of the ladies I saw today was from the town where they make Hatteras boats, and I have a super old, very cheap, but I love it, Hatteras boat.

And she was telling me about Hatterases and her husband makes a lots of money designing. He's designing somebody's $10 million boat right now. Anyways, we talked about boats. That was fun for me learning .... She was a new patient. Learning about her and her knowledge of boats because she's helped make them before. She's from the town where lots of people do that. They build Hatteras boats. It helped me understand her more and it made my day better.

The person before her was from my hometown and we talked about some dive that we both used to hang out at in Birmingham.

So let's say that you like to do that too. And a Botox treatment, even though you can do in five minutes, takes you 30 minutes.

An eternity, right? A 30-minute Botox treatment is more like visiting with your mama. All right?

So how many ... If you saw them four times a year, how much time are you going to spend with them?

That would be two hours. All right, and let's just for ... Something to get an idea about. Let's say that you have ... And the reason I'm picking this number is I noticed that my income approached what it was when I was an internist working a lot with people in the hospital answering the phone. At around 300 people on my email list, I was doing what I did as an internist.

But let's pick 250. So if you did 250 people times two hours, that's 500 hours.

All right? Now, let's make the math easy and let's say that you take two weeks off per year, so you only work 50 weeks out of the year.

That means that you only have to work 10 hours a week, 500 divided by 50, that would be 10 hours.

So 10 hours a week to take care of 250 people who are going to net you $250,000 a year.

This is why some people make millions just doing Botox parties. It's been done more than once.

That's 10 hours a week and all you're doing is neuromodulators and you're talking with them like they're your lost cousin for Thanksgiving dinner. You're not even rushing people through, and you haven't done anything else with them.

So where does it fall apart? Why is it so hard for people to make profit?

It's because they get rid of the pimp, and they get what I call ... Okay, I'm just going to give you an Alabama term. I think that some people make blood, and some people are what I used to pull off of my bird dogs behind the ear.

They would get this thing called a tick, and those ticks would get so fat from sucking the blood out of my dog.

By the way, if you want to know how to get a tick ... This is an old ER trick. If you want to get a tick off of you without leaving its innards into your skin. Actually, I didn't learn this as the ER doctor. I read it in a Red Cross book when I was about seven years old after getting a tick on myself. You just pour a little motor oil on it. Since the tick breathes through its skin, it starts to suffocate. It lets go and try to just ... crawls away. So there you go.

Anyway, some people make blood and some people suck blood.

And in my opinion, every employee, if you look at the numbers, you should only be spending somewhere around 20% of your money, your gross, on employees.

So what I tell my employees is that when you're bringing in five times what I'm paying you in gross, because by the time I pay your taxes and I buy your insurance, and I buy the place where you sit and the space where you stand in the office to do whatever it is you do and pay taxes on the money you bring in, I can't really afford to pay more than 20 to 25% on employees. So that's their guide. When they're making 5X what they're bringing in, it's time to ask for a raise. If I'm paying them ... If that number's out of kilter and they're only bringing in $100 metaphorically and I'm paying them 50, their job is at stake.

And of course, so what happens is everything in your office should be that way. And the reason people struggle is they have machines that are eating away at their income, not bringing them 5X or even equal to what they're paying for the machine.

They have people that are costing them more than they're bringing in. And then you have people driving around in their sports car making a cool million dollars a year with no overhead, basically just doing Botox parties.

So that's a long way of saying if you're trying to go all cash and you can keep your overhead reasonable ... Now, if I can have an employee that makes me 5X what I'm paying them, another 20%, in other words, then I'd like to have 10 more like that employee, as long as there's enough business to go around.

Right?

And so they're your nurse practitioners and your estheticians and such.

Now, the hospital used to call an ER a money loser because, in the scheme of a hospital, so many people come through that are non-payers, but they had sometimes to lose money in the emergency room because they had to have one or they couldn't be a hospital. And you may need someone who answers the phone that doesn't do any selling, but as much as possible, try to make sure everyone in your office has a job that brings ... something they're doing is bringing in 5X what you're paying them.

Maybe it's they're calling and doing reminders and bringing back people that would've not re-booked or that missed their appointment, so they get back in, and that's money too that would've been lost.

So I'm not here to try to be the success guru. Most of you are already making lots of money, and all of you are successful, or you wouldn't even be a part of our group. But the point I'm making is for the new people, you can see, can reach the 250,000 a year mark working 10 hours a week just doing Botox if you keep your overhead low.

Let your business pay for your business. And if you want to make a million a year, okay, work 40 hours a week, and by then, you're going to have to have some employees. But let the person answering the phone also sell the cream or do facials or something.

They're on the phone answering and selling people into coming to see you that you don't have time for.

Okay, that's all I have to say about all that. Let me see if there are any questions. If not, we'll call it a night, but I hope that you'll click on that link that's in the chat box.

Okay, I think that's it. Hopefully, there was something helpful tonight. Grow your list. Have a list, grow it, watch your overhead, and have a good time.

You guys have a good night. Goodbye.

Relevant Research

Relevant Links

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Dr. Runels Botox Blastoff Course<--

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