Okay, the, uh, the next lecture is a Lauren Hatch Memorial lecture. The title is the business of occupational medicine, right? So it is being presented by Lance Walker, D. O. M. P. H. F. A. O. C. O. P. M. Dr. Walker completed undergraduate training in biology at Julian Jewel College of Liberty, Missouri. He received a doctorate degree in osteopathic medicine from the Oklahoma State University College of Osteopathic Medicine. His residency was completed in family medicine at Floyd Medical Center in Rome, Georgia. He served as chief resident. After residency, he entered private practice in North Carolina, where he co-founded and managed to be successful practices in the Raleigh-Durham area. He received a master's degree in public health from the University of North Carolina in 2005. Now, the Lauren L. Hatch Memorial Lecture in Occupational and Environmental Medicine is given each year in honor of Lauren L. Hatch, D. O. P. H. D. F. A. O. C. O. P. M., a founding member of the College and the Division of Occupational and Environmental Medicine. He served as president of the College in 1981. He was designated a fellow in 1985 and a full professor under the faculty status in 1998. Dr. Hatch served as a member of the American Osteopathic Board of Preventive Medicine. Dr. Hatch was affiliated with the National Institute for Occupational Safety and Health, where he served as an occupational medicine consultant to the Division of Technical Services. He was a prolific lecturer and author and accomplished much to advance the field of occupational and environmental medicine. Established in 1991, this prestigious lecture is presented each year to an individual member or non-member who has demonstrated a desire to see occupational and environmental medicine excel for the public good. It is my honor to present the Lauren Hatch Memorial Lecture plaque and award to Dr. Lance Walker. Awesome. Thank you very much. So title of the lecture is Business of Occupational Medicine. The subtitle I didn't actually put it on there is how to turn your D. O. into D. O. U. G. H. but I thought I didn't want that out there probably. So first off, I'm not Tony Robbins. I'm not. It's not a get rich quick thing. I got nothing to sell you. I don't even have a book. So what I'm trying to give you is some of my experience, some of the things that I've done in my practice. And I'm going to talk from experience only. I'll discuss in detail things that I've actually done. So a little bit about me. I grew up in Missouri, a little town called Kirksville. I got a B.A. in biology at William Jewell College, which if you ask anybody around here, they will say that's the Harvard of the greater Kansas City metro area. I finished family practice residency in Rome, Georgia in 2000. I've been in practice for, I guess, 23 years now, which seems like a long time. But in 23 years, I've always worked just for me. So I've never been an employee of anybody. I've been a contractor and things. So I started a traditional family practice setting in a rural North Carolina town. I saw 35 to 40 patients a day. I admitted patients. I took call for the E.R. I did my own rounds. I managed the nursing home. I did house calls. I did everything a typical family practice doc would do. After a year, I pulled in a friend, Dr. Gonzalo Fernandez from residency. I said, hey, I'm real busy. I can use some help. He came up. We started the first urgent care in town. Eventually, we were working 10 to 12 hours a day. We were stressed. We were having a hard time. We started looking for ways that we could decrease our work time, increase our revenue. We made a few good moves. We started the first hospitalist program up there, basically hired somebody to take our call, which worked out great. And still, getting rid of the hospital was great. About the same time, we're sitting there, we're doing our family practice, and a nurse from Progress Energy comes over to our practice. And she says, hey, guys, we've got two coal-fired plants just about 20 miles from here. We need help doing our emergency response team physical. The company we're using right now, they're not doing a good job for us. Can you guys help us? And we said, well, what do we have to do to do these emergency response team physicals? She says, well, you're going to do an audiogram, pulmonary function test, urinary drug screen, respirator fit testing. Our eyes were blazing over. We're like, yeah, yeah, we didn't do this in family medicine. They said, please go away. And she did. But fortunately for us, she came back. She said, no, I really, really, really, really need your help. I will teach you what you need to know. And I'll help you through it. And she did that for us. And that was really our first introduction to occupational medicine. For us, the real eye-opener came just a few months later. One of those plants had a big outage. They brought in 3,000 contractors from Flora Global. And they needed, at the time, Progress Energy required them to have pulmonary function testing as well as respirator questionnaires. And so we set up in a little strip mall. Our office wasn't big enough to handle that. We moved across the street. There was an empty little strip mall space. We rented it for a weekend, three or four days. And in that three or four days, we made more money than we would an entire month of seeing family medicine patients. So that got our attention. Maybe there's some other things we should be doing. And so what I'm going to kind of do is kind of walk you through the last 23 years, talk about a few opportunities as they came along kind of chronologically and how I looked at them at the time. For some of you, you guys are at least here in the room. I know we're mostly experienced OCDocs. Some of these are going to be no surprise to you. When I've given this talk before, I've done it for family medicine folks that don't have as much experience. But you may find something here that you didn't think about that might resonate with you. So following along. So the early years, I call these the bolt-ons. Basically, what we're looking to do was add things to our existing family medicine practice that we could kind of blend in with what we're already doing. So starting out with CDL exams, commercial driver's licenses. Most of you back then, you didn't have to be certified. So it was real easy. Just said, I want to do it. Started doing it. Most of you here in the room are probably certified medical examiners. If you're not, the course actually starts this afternoon. You'll be sitting there with me because it's been 10 years since I was last certified, even though I helped to write the course and teach it and taught it at one point. At that time, we charged $55 per exam. I'm going to talk about money a little bit. And so if that offends you, this is your PPE. Put your hands over your ears if you don't want to hear the money talk. We charged $55 an exam at the time. For us, looking at it from a family medicine doc, and we didn't certainly know what we know now, it was in and out. No prescription, no follow-up, no late night calls for the most part. I mean, every now and then. But we tried to get about 10 per week. So that added $30,000 to our bottom line as a practice. That was good for us. Our practice was also in a pretty small town. So it was really easy to know, where are the truck drivers at? Who needs these physicals? Well, they need it over there because we know they are trucks. And so it was easy to pick up the phone and call a few places, put out a few brochures. We got a little bit, we got some business. So we started getting that going. I still do some CDLs now. I charge about $110. I don't know what y'all are charging. And really, the thing we've done over the years with this was try to start identifying large concentrations of drivers and then going on site. So for Georgia Power, we'll do 25, 30 physicals in a concentrated period. So you can make a lot of money in a shorter amount of time. So if you think about this, you extrapolate $110 for 10 exams a week now would be $55,000 for your practice. Flight physicals. Nobody here knows anything about that. So originally, my brother-in-law was in the Air Force. He's now with Boeing as a test pilot. He came up to my office when I was in North Carolina. He says, hey, you know, I go to this flight doctor. And the dude just whispers, he goes, how have things been? Can you hear me? And he listens to my heart and he gives me a certificate. He was like, it's so easy. You should do this. I'm like, wow, that sounds great. I really, I want to do that. And he says, you know, he charges me so much for it. I said, that'd be great. Well, then I actually went to the course and I was like, well, this is harder than he told me. But, you know, it was, it was good. And so at the time, you know, once I, once I learned, I trained, trained my staff to do them. The typing of the certificates was actually the hardest part because my typing skills were horrible. It's bad. So now that's all, you know, obviously computerized and it's so much easier. Back then, I was charging about $65 an exam, which added, and I was doing three to five exams a week, which added about $13,000 annually to our practice. I'm still in AME. Last year, I performed 86 exams at about $110 each. So still doing not only work, I only work in the clinic like a half day a week. So that's $94,060 in income. I'm sorry, $9,460 in income. Now I do Dobbins Air Traffic Control, some local private pilots. And I have, next door to me, I have a drone shop where they've got 70 UAV pilots or whatever the new term is that we're calling them. And they, so I have to do all their class twos. And that's, that's a good little, good little gig. You know, certification, I've got the, I've got the link down here. Certification week-long course still in Oklahoma City and then periodic training. And it's a, it's a great thing to do if you don't do them already. You get 32 CMEs. And the CME, of course, of course. Immigration physicals. This is one of those where sometimes a casual conversation can make all the difference in the world. My wife had a physical therapy clinic. She hired a physical therapist from Australia. I'm having, we had dinner together. I'm talking to her and I said, she said, well, you know, I had to do this immigration physical. And I went to this doctor and, you know, I get my, my, my immunization history. They did a physical exam. They took some blood. I peed in a cup. And, and the guy charged me like $400 and it was really expensive and he wouldn't take insurance. He only took cash and credit cards. And I said, huh, that sounds like something I want to do. I want to do that. And, and so, so we did, we actually did. So Dr. Fernandez, my business partner, we said, well, let's get you on this panel. So you have to apply to be a civil surgeon. There's an application procedure. I know the secret sauce. I'm 3 for 3 on getting people on the panel. So, if you want to get on panel, we can talk about that later. The, it's a great way at the time with expenses, and after you take out expenses, we were clearing about $200 per exam at our peak. We were doing about 20 exams per week, which added $200,000 to our bottom, which, which was great. Later on, I got on the panel, both Dr. Fernandez and I continue to perform the exams. I do my little half day that I work in the clinic in Georgia. I see about 5 a week. So that's about 30. I'm sorry. That's about 50 grand a year. Dr. Fernandez in North Carolina. He does this. This is really his little thing. He does about 30 a week. So it's $300,000 a year profit. That's after expenses. So, and like I said, we can talk about getting on the panel disability exams. So scary disability exams as a resident, Dr. Fernandez contracted with a chiropractor and in Georgia, and to perform social security disability exams for the state of Georgia at the time. He was getting paid about 45 dollars an exam. He was performing 2 exams per hour as a resident 20 years ago. $90 an hour is pretty darn good. But realizing the chiropractor was taking all the rest of the money, so he was getting about a 100 dollars per exam for everyone that Dr. Fernandez did. So, when he joined our practice in North Carolina, we decided we'd continue to do that. We, at the time, North Carolina was paying about 135 dollars per exam, including your dictation. We blended about 5 exams per day into our patient flow, added about 168,000 dollars to the practice. We were also about 15 miles from Virginia. I'll talk a little bit more about cross state stuff. So, we also called the Virginia disability folks and said, hey, if you'll send them down to our office, we'll see them down here. And so we got Virginia. So we had North Carolina and Virginia folks come into our office. They are non diagnostic exams. I really consider them confirmatory exams. So, a person applies to the state social security office. State basically pays you to take a medical history, perform a physical, document your findings. It's a federal program. It's administered at the state level and there's an individual. Every state has a special relations unit, and that's really going to be your 1st contact. And I put that down here. The impact on revenue was really good. You can think about adding these into an existing practice or adding on a Saturday or day off. If you perform 15 exams a week, could be up to 130,000 gross. If you're good with your expenses and keep your expenses low, it could be about 115,000 dollars a year. There's other opportunities to where you can do pulmonary function testing, labs, records reviews where they'll pay you a little bit extra. So, satellite office, so at the time, imagine we're blending some of these exams into what we're doing with our family medicine patients. So we're seeing sick people and then we'll see a disability or we'll see a flight physical. So we started thinking to ourselves, you know, this is really adding up. You know, if you add all that up, we're bringing in 400,000 dollars to our little family practice, and an average family medicine patient was costing us about 85 or getting us about 85 dollars in revenue. On these, we're getting closer to 120 dollars in revenue. And so we're thinking, hmm, to make that money, we'd have to see 4,700 patient visits or about 1,400 fewer. If we just do these awkward kind of things, like, hmm, we might want to do that. So we said, well, what would we have to do? So we called North Carolina Disability Determination Service. We said, hey, where do you need these exams? If you could put me anywhere in the state, where would you put me? They said, we won't put you in Garner, North Carolina. I said, all right, cool. It's like an hour away from where we are. And so Gonzalo and I went down to Garner, and we said, started looking at office space. And as we're looking around, we looked around the hospitals, and I'm like, this is really expensive space. This doctor space stuff is expensive. But then we went to, like, an industrial park, and we said, wow, it's like a third of what they're paying. And so we went to the guy to rent the office, and we said, hey, his name was Don. And I said, Don, we're going to rent this office. And what we're going to do here, we're actually real doctors. We're going to rent this. We'll be down here two or three days a week. We're not going to see sick people. And he said, you guys are never going to make it. What are you talking about? I said, no, not really. It's for real. And we still actually rent that same office. So it's another one next door. We had a little heating and air place, a little church next door. But it was great. So think about if you're thinking about renting an office, don't do it in the doctor areas. Go to the industrial park. Find yourself a little space somewhere. So we started, we had Gonzalo start working the satellite office just a couple of days a week. I would do one. We backfilled our family practice with some PAs. They filled up all the weekend hours, took all of our weekend urgent care stuff. So we didn't have to do that anymore. We generally see, so our mix of patients down at the little satellite office, we see about five immigration exams, 12 disabilities. Daily income was about $2,600. So daily cost for rent was $125, $240 for a medical assistant. So daily income, about $2,000 a day or $250 per hour or $300,000 a year for three days of work per week. Again, you can, you don't have to rent your own office. You can sublease from another doc. If you live near a state border, sometimes getting a license and going, you know, contemplating, I'll get a license up in Tennessee. I'll go to Chattanooga and see some patients up there one day a week or two days a week. So just keep an open mind on that. The move. So after a couple, I had a couple of kids, my wife and I, all of our family was in Georgia. So we're driving back and forth, burning up the interstate. We said after a while, you know, I'm a doctor, you're a physical therapist. We can work anywhere. So we sold our family practice. Gonzalo and I sold the family practice to our physician assistants, actually bought it. So had a little bit, we kept the satellite office in Garner. Gonzalo said, I'll keep that one. Had a little bit of money in my pocket. And I said, I don't really have a job in Atlanta, but I'll figure it out. But let's find out where we want to live first. So we went that way. We got all over the city, looked around, ended up in Marietta, Georgia. And so, which, of course, is the garden spot of all of Atlanta, if you need to visit. So after a while, though, not really working, I checked my bank balance and I said, I'm going to actually have to go back to work. And I didn't really, like I said, I didn't have a job. I had a degree and I had a Georgia license. So the easiest way and the quickest way to make money is locums. And, you know, I had small children. My wife is like, you're not traveling the nation doing locums. So, you know, Atlanta's a big town. There's a lot of options. I hooked up with one of the local hospital groups. They had a large primary care network. I just started filling in for their doctors. It was fun. I enjoyed it. It's not for everyone, but it was good to no overhead. It paid pretty well. I then also found a company out of Pennsylvania that was doing exams on site. It's in local industries. So, hey, this sounds good. It's a good experience for me. I want to do more of this kind of stuff. Pay at that time was seventy five to one hundred dollars an hour. I could pick my jobs, work as much or as little as I wanted. Great way to make ends meet. Good, good experience while I was contemplating next steps. So military and processing really got at least to talk about this today because I actually did this for a little while and it is a great gig in Atlanta. The map station was about 20 miles south of me, be sure to explain. You review the medical records, do a physical exam and it was it was good work and it's enjoyable. It was the traffic in Atlanta got me that I was like, I can't I'm not going to keep doing that. But but it was I really enjoyed doing. Veterans disability, you know, these are exam form usually for a third party to help veterans get disability ratings, subsequent compensation. There are several companies performing these. I understand the contracts going to be. Yes, I think QTC. Okay. But as a transition, but so the contacts may change. At the time, I just called them up and I said, what do you need somebody to do these exams? I've done this. I said, mobile Alabama. No, no, no, Montgomery, Montgomery. I said, I said, all right, cool. Montgomery. So they pay for me to spend the night in a hotel. I'd wake up the next day. I do the exams. Um, you know, I could generally count based on the number of worksheets or how many people I'd have to see generally count on that being 750 to a thousand dollars a day. Um, I found him pretty tedious. I was talking to John about the documentation and apparently they may be starting to pay for some of your documentation time, but they are tedious because if you're going to do a good job, you, you have to take your time and you have to document correctly. But for the right person that's pretty efficient, has done it a lot, it could be a really good moneymaker for you. You can also add these to your existing location. So, you know, ask them if they need them where you are already. You don't have to travel necessarily. The other thing is, if you have your own office and you don't really feel like doing these, they will also rent your office space and put a practitioner in there. So, if you have space, they will pay you for it. And something like 300 bucks a day, which is really pretty good, which is I try to when I rent space, I try to pay 150 to 250 a day. So, if they're paying me 300 dollars a day for space, I'm not using them. I'm all about that. So, after a while, I was traveling, I drove over to Montgomery, and then I was doing the MEP stuff and working a little bit. So, finally, I figured out, I'm like, well, and I was working some locums. I said, you know what? I don't really have to drive anymore. I can actually just do this. I don't really know how to do this. So, I went around. I said, all right, I'm going to draw my little circle. I'm going to do it two miles from my house. So, I'm going to find an office within two miles of my house. And so, I had every chiropractor up, every doctor that I could find. I said, you got any extra space? I'll pay you 150 dollars a day. And so, I found a guy a mile from my house, and it was great. No commute. And it was a great office, too, because it was a busy internal medicine office. And they had some other stuff going on there. They had some drug screening going on. They had a lab core draw station. They even had a clinical research group, which I'll talk about in a minute. So, clinical trials. So, the clinical research group. So, I set myself up in a little office. I started doing immigration, disability, flight physicals, and CVS. And I was starting to see overflow patients from the internal med guy. He'd have extra people he couldn't see. And I'd say, all right, I'll see him. You know, he'd give me a cut. Cool. This is great. Clinical trials. So, the building I was in, they had clinical trials going on. They needed physical exams periodically for some of these folks. They'd pay me 75 dollars an exam. Didn't take any time. Low stress. And I, you know, they'd line up five or six. I would do that. You know, that added 15 to 30 thousand dollars a year with no overhead. There are some training, you know, if you want to get into clinical trials, and you want to become an investigator, you do that right. Take the right training there. You don't just set up your own shop. You can't experiment on people. So, teaching. I did this. This is a lot. Teaching for me is a lot of fun. I enjoy it. I did it for a few years when PCOM opened up. I actually, they were there before I was there, but they're fairly new. I picked up the phone. I said, hey, you need somebody to help teach something. I said, sure. We primary care skills. This is cool. So, went over, started teaching primary care skills, doing labs, helping out with testing. Really enjoyed it. Pay was, you know, it wasn't awesome, but 75 bucks an hour or something. It wasn't bad. And I enjoyed it. And, you know, think about it now. There's, you know, when we started, there were like six or seven D.O. schools. Now there's 4,000. So, there's probably one in your backyard that you could go work for. I've also taught an I.S. spirometry course and chaotic audiometry courses. You know, any chance you get to teach, maybe it's in your local high school or something like that. You know, it's fun. It's something outside of strict clinical practice. I.M.E.s. I thought this one was going to be the home run. Like, I was sold on this. I went, I took the A.B.I.M.E. course in Vegas, which was really hard because I was locked in this course and I couldn't go out and play. So, for two days, my wife was having a great time all over Vegas. So, I got certified. I put out some feelers. I got a few exams from some insurance companies, but it wasn't as much fun as I thought it would be. For some of you that are real type A and real detailed, you may love this. You know, review records and give all your opinions. I found it to be kind of time consuming. I charged about $500 an exam. I was probably getting ripped off. But, for the right person, it could be a good fit. I still do a lot of fitness for duty assessments. I don't do, I don't do strictly I.M.E.s, but I do fitness for duty for police and fire, things like that. M.R.O. I've been an M.R.O. for over a decade. After I got certified, I partnered with a collection site to be their M.R.O., liked it. I then started calling some T.P.A.s and asked, you know, hey, do you need an M.R.O.? And they said, sure. I landed in with a T.P.A. They were doing all of the Popeye's fried chicken franchises. And I guarantee there is a direct correlation between chicken prep and marijuana use. And it was really good. At the height, I was making about $2,000 a month for a couple hours of work a week. I keep my M.R.O. up still just because I have a few clients and I do it as a favor. And I also like to keep recertifying because the knowledge, I think, is really good. Even if you don't want to do M.R.O. as an OCDOC, just having that course and having that knowledge is a really good thing. Wellness and health fairs. Companies are always looking for interesting ways to emphasize the health and wellness of their employees. Georgia Power wanted to increase access to medical professionals through one-on-one physical exams. So we asked me to do that. I said, sure, we'll go on site. We perform vitals, vision, urinalysis, EKG, physical exam. We review their company-sponsored lab work with them and basically give them recommendations they walk out with. So we do these now with a nurse and a P.A. Sometimes I'll go if everybody else falls through. But we go all over Georgia and Alabama. We try to schedule 15 to 20 exams a day. Last year we performed over 500 exams at $120 a exam. Daily costs, roughly $800 for a nurse and a P.A. We make the company guarantee us 15 exams per day. So if they have 10, they pay the extra five. You know, so each day you can probably make a thousand dollars in profit in this kind of that kind of work. Associate medical director. Once you start doing work with companies, don't forget to look for opportunities and ask them if they need a medical director. I had just moved to Georgia and we started forming emergency response team physicals and CDL exams for Georgia Power. And we were going to their sites all over the state. Apparently, we were doing a good enough job and I had good interactions with the medical staff and the big medical director there. And at one point they said, hey, we're looking for a backup medical director. I said, huh, what does that pay? And they said, well, it pays this much. I said, what do I have to do? They said, well, we're going to order all the wellness labs under your name. You basically supervise the protocols for what the what the wellness nurses are going to talk to the people when they go over their labs with them. And if something happens to the medical director, you're the man. I said, okay, that sounds good. I would like to do that. The one thing I want to focus on is as a consultant, you want to make sure that you get paid for your time. So know what your time is worth. You know, if they're asking you, we've done this two different ways. So Dr. Fernandez was also medical director for Progress Energy for a while. He nickel and dimed them. So everything was, you know, if I pick up the phone, it's five minutes. If I if I drive here, it's this much. If I do a consult, it's this much. I'm a flat fee kind of guy. I'm more of a I'm like, I'll take this much money and I'll do this much work. And if it doesn't work out, I'll let you know if it's more than I can do. So so that was a good start. Anyway, so I started that relationship. On-site exams. So it's a bit more advanced topic to do on-site stuff. Sometimes it may require more resources than you might want to commit, but not all the opportunities are super labor intensive. For example, we just signed a contract with a weapons manufacturer. They have some anhydrous ammonia on site. They had about 50 emergency response team physicals that they needed done. They're right by my office just down the road. They were sending everything to this little Ahmed National Clinic, and apparently there are people waiting at least two hours. So plus an hour drive time back and forth a half hour each way. So they were spending 150 paid paid hours to complete 50 physicals. We can go on site and we can do them in two shifts. So 16 hours, I can knock out all those people. And so it's good for them and it's good for us as far as a good profit. So good targets for that kind of work. Any industry that has fire brigade, security teams, emergency response teams. Think about, you know, biomonitoring if you like lead. I haven't done any of that, but I know there are companies that need periodic lab draws. Maybe you can go out there and draw it for. We've taken it. We took that concept of doing on-sites. We said we're going to expand this. We're going to do mostly to firefighter exams. So now we found a company called SiteMed. We take teams on-site. We provide firefighter exams. And we've done pretty well with that. We're doing physicals in about 14 states now. No beginning for on this? Depends on what all they order. Just went up because of inflation. But base for just standard physical, which includes EKG, PFT, audiogram, somewhere depending on how far. So base is about 340 up to 500, depending on the zone. It's kind of zone pricing. Okay. So, yeah, well, consensus circles. Exactly. So current situation, last seven years or so, fire department physicals doing well with that. I continue my work with Georgia Power. Still performing, you know, state disability exams a little bit. Immigration, CDL, flight physicals. In my office, the large mega hospital in town came over and they bought the building that I was renting my space in. And they said, we want to pay you X amount for your practice. I said, that's not enough. They said, well, you can find a new place to be. I said, okay, well, that's good. I will do that. So I went around the corner. I found actually on the same street, I found a little industrial park. Got in there and actually bought the office this time. So I had enough money. I said, I'm just going to buy it. So I bought my space and again, it was much cheaper than buying it in a doctor office park kind of thing. I get bored though. So I didn't just want to keep doing what I was doing. So I'm always looking for other things that I can do and interesting things. Expert witness. I've done this a few times because I help with the help ASCOPM develop the driver's course. I had the opportunity. Lawyers just called me up. They find my name on some slide somewhere. And I've done two or three big truck driving cases, big cases that were really interesting. Some fatality cases. I thought the prep work was a lot of fun. I even enjoyed doing depositions. It was all right. I didn't get rich. Each case, though, was 5, 10, extra thousand dollars for me. I know there's training courses you can take to be an expert witness, but apparently I did okay. So without that. And there's really no overhead for the most part. The work can be done from home in your pajamas. And as long as you don't have to go to court, you should put something on if you're going to court. So I always try to. And again, you guys do this all the time. Might tell me I'm low balling, but I try to get 500 dollars for home for work. I do at home and about a thousand dollars for deposition or court testimony. That's per hour per hour per hour. Good. Yeah. Not per day. Not per week. Supervision of physician extenders. I've done this in a lot of different forms. I've contracted with companies directly that have clinics, both family medicine and clinics in this model. I'd love the middle level operator. My license. I review a certain percentage of charts be available for questions. I was charging 10 dollars per hour for my deposition. I was charging 10 dollars per hour work by the mid level. So every day, every hour they work, I get 10 bucks. And and then they came to me after a while and they said about 7 dollars and 50 cents. I said, no, 10. And they said, okay. And so they continue to pay me that. But they will try to, you know, they would try to cut you down at the peak. I had about seven working under me. That was about 4000 dollars a month. It wasn't hard. I kind of enjoyed it. But but I found that that after a while that some of the practitioners were not following standard guidelines. So I had to terminate relationships with some of them. That didn't make me very popular. So eventually they stopped giving me people. But but it was, you know, it was good for a while. But recently, I actually I have a mid level I've been working with for about 10 years, and she's developed her own little practice doing periodic health assessments for the military. And so she rents space from me in the office. She works under my license. She pays me a little stipend. And she's doing she's trying to replicate this model and others with her friends and other places. And so I will be their supervising physician when they do that. And I'll do, you know, $10 an hour, about $100 a day is what I'm asking to do that. I'm hoping I can get four or five of those going. And that'll be a nice little revenue streams. Another another thing to think about, I talked about doing the state disability exams, the states are now allowing some sometimes some of the advanced practitioners to do the state disability exams. So you could supervise them, like Dr. Fernandez was, like the chiropractor was doing for Dr. Fernandez, and you could take a cut for just being a supervising physician. Medical directorship. So really, what I want to want to say about this is that, you know, I've after about five years, I was the assistant medical director, I was kind of like Prince Harry, I was a spare. And, and then, and then something happened, they didn't get along with the big guy. And they came to me and they said, Hey, do you want to be the real medical director? I said, well, sounds good to me, I'll do that. And so so I got promoted. And then COVID happened. And with it for Georgia, Georgia Power is the largest unit of Southern Company. But we have all these other units that that we have telecom company, we have a solar company, we have a gas company. And they didn't have medical directors. And so with COVID, it became pretty obvious that they needed medical leadership. And so I got a little more promotions, which was great. So I took over some some more responsibilities. But don't forget, like, when you're thinking about medical directorships, don't forget smaller entities may need a medical director, they may need to steal a part time, like your fire department, your city, your county, some local industries, you may be able to find something where they'll pay you a little bit to be to have access to you. And it may not be a lot, but it's fun. And it can always lead to new opportunities. Athletic trainers. So recently, I started working with a company that place athletic trainers in industrial sites, you know, doing coaching and doing some injury, rehab kind of stuff. Those guys needed standing orders in in multiple places. So I provide the standing orders. And again, I went back to the $10 per hour work model. So so they pay me pay me that I've got basically bill them out quarterly for that. And that's, that's been a good relationship. And it's led to because they're in these industrial sites, when something comes up for these industrial sites need, then they can feed that back to me to say, hey, can you come on site and do our security team? We can do that. So so it's been a good, good back and forth relationship, sort of unexpected opportunities, and this is sort of the I want to get at the being prepared for whatever life throws at you, you know, COVID brought a lot of great opportunities. I was asked when COVID hit, we Southern Company, we're building two nuclear reactors over by Augusta, Vogel 3 and 4. Vogel 3 just came online. So they're starting to ramp it up, doing like 18% production, but they had 10,000 contractors on site at the beginning of COVID and they called me and they said, hey, we're really worried that if this, you know, if we have an outbreak, if it gets out into the news, if we have a bunch of dead people, we may have to shut down. And if we shut this thing down, we may never get it back up. And so they said, we got to operate through, we got to continue construction through COVID. And I said, well, I'm not an epidemiologist, but I am a member of ASAOPM and I know an epidemiologist. So, so I pulled in Melissa Oberman as our epidemiology advisor. I pulled in another doc that was a former, I pulled in Dr. Fernandez, who's a former medical director for a power company. And our little group served to advise them all the way through, through the pandemic. And, and it was great. And then out of that opportunity, they said, you know, what we need here, we need 24 hour testing. And so we were able to stand that up within 48 hours. We had people on site doing 24 hours testing and, and then, you know, sending, sending samples and, and managing all the quantities that we needed to be able to do that. contracts in place with a local imaging center, you know, any of your ancillary services. When I evaluate opportunities, I kind of have my little paradigm I do. Every opportunity is not a good opportunity. First off, is it legal? You know, I've been presented with ideas that are, frankly, illegal, and I'm—no, not for me. Is it ethical? There are ideas that are legal, but they're not right for patients, you know. They're bad medicine, or they're exploitive of people. I was once offered $10,000 a week to write prescriptions for oxygen concentrators for patients I never saw, and I wouldn't have follow-up. So not even for $10,000 a week, is that worth it? Are you covered? So I've had to change my malpractice carrier early on because Georgia Power required specific language in there that my malpractice carrier said, no, I'm not doing it. And my malpractice carrier also said, those Georgia Power people that you're ordering wellness labs on, they're not your patients. We don't consider them your patients. We only cover doctor-patient relationships. And so I had to change insurance carriers. Also, sometimes your carrier won't cover you in certain states. So for me, my carrier covers me in 49 states and D.C., and I have to have another policy for Kansas. So that's the top. Do you have the right training? You know, have you taken the right courses? Are there certifications you need to do? Are you prepared? Do you have your team in place? Are you structured correctly? Do you need a lawyer to help you? Do you have a good financial advisor? We talked a little bit about that. Have you thought about who you're going to hire and how you're going to pay them? What's your return on investment? Is it worth it? Every opportunity comes with a cost, whether it's time or money. What do you stand to do? What do you stand to make if it works out? And don't be afraid to say no. Every opportunity is not a good opportunity. No, I'm not going to do it. What else do you have? Marketing and pricing. So marketing, you know, some of the marketing you don't have to do. Disability exams. You don't have to market for disability exams. The state's just going to send them to you. So it's easy. But a lot of the other stuff, you need to put a little effort out there to get some business going. You need to know who the right person is, the right target, who you're supposed to be talking to. Is it a TPA? Is it somebody in HR? Is it somebody in safety? Is it a plant manager? Is it the fire chief? Is it the mayor? Is it city council? Speak their language. So learn what they're, you know, don't talk doctor to them. Talk about what they need. Ask them. Dr. Peters in the chat has a question. I don't know if he wants to unmute and ask, or if he just wants to leave it. Let's, can we do them after? Let me finish. Yeah. So, so you want to, you want to make sure you're speaking their language. Ask them what their pain points are. Right medium. So is it a direct meeting? I always like face to face if I can get it. Is it a, you know, express interest, do a plant tour, give them a brochure? Is it your website? Do you want to have a specific website for every little service you do? We find that works really well. We have a specific website for immigration. We have a different one for on-site firefighter physicals. We don't lump it all into one big website. Right price. If you're overpriced, you're not going to get business. If you're underpriced, you may end up setting your price too low and it's hard to get your prices up. Right frequency timeline. How often do you contact somebody and how many times? Probably three to, you know, they say it's like seven contacts before you get a contract. It can be a lot, but just, you know, be persistent. Right person. Early on, I was able to find an old retired guy who used to sell concrete and Polaroid film and I was having a drink with him and he said, I can sell anything. I said, can you sell firefighter physicals? He said, yeah. I said, will you take 10%? If you close anything, I can't pay you anything up front. He goes, yeah, I'll do that. And so he's still, you know, 15 years later, he's still selling firefighter physicals for us and makes a good living doing it. And still makes tempers. Pricing. Pricing is difficult for physicians sometimes. Physicians like to follow that insurance model on pricing where you say, all right, look, I'm going to do, I'm going to come on site, I'm going to do a physical exam. That's, that's 150. I'm going to do an EKG. That's another 150. I'm going to do an audiogram. That's another 150. I'm going to do a spirometry. That's another 150. I'm going to do a, I'm going to do a respiratory questionnaire. That's another 50 bucks. And so you do that, your price blows up. And it's not, that's not the right way to price for most of these kind of services. There's a few different ways, you know, obviously, some people in disability exams, they're going to pay what they're going to pay you. But if you set your price too low, you're going to lose money, hard to get your prices back up too high, you miss out on business. So a couple of ways, so market pricing, how much are they willing to pay? What are they paying now for similar services? You want to be ready to justify if you're asking for more than what they're paying now. Do you get better service? Are you more responsive? Are you faster? People will pay more sometimes if they're unhappy. Don't forget that most contracts that are government contracts are public records. So you can go look up and find out what they're paying, even if they don't want to tell you. The, if there's urgency, sometimes they'll pay a little bit more, like if they've had an injury or OSHA has been in there, and they realize they have a problem they have to fix fast, ask questions, find out what, find out what's going on, why they need somebody. Sometimes there's a grant involved. So we've had fire departments, they get money and I'll come in with my price and they'll say, well, wait a minute, we've got a grant and we've got another $100,000 to spend. Okay. I can help you spend that. We can come up with some more stuff we can do. So, so yeah. So, so always ask, you know, what's their, you know, they may, what's their funding? Do they have a grant they need to spend it all? So they can get it again next year. Don't forget that if you're doing ancillary services, you want to make a profit on basically everything that you're doing. The, yeah, the other way to, the second way to set pricing. So you don't, let's say you go in, you don't have any idea what they're paying. You have to set your price. We usually do that. We back into our pricing, we figure up our expenses, and then we target 40% profit. You have to be careful when you do that. You have to include a portion of your fixed expenses. So your rent, your insurance, your electric, your phone, you know, find out, you know, if you don't get the job, find out why. Are you too expensive? Is it services? Something else. You can always adjust. If I'm doing consultative work where there's little fixed costs, it's different. Like I said, I try to target $300 to $500 an hour and a little bit more if I can get it from the lawyers. If I have to travel, I make sure I get reimbursed. Beware the loss leader, because you might take a contract at a cost or just above cost just to get your foot in the door. Sometimes that works, because you can expand it into other things. We did all of Georgia Power's audio testing with a truck and a tech. She drove all over Georgia for a year. We made $12,000 after the whole year, and it definitely wasn't worth it. But as a loss leader, it was probably worth it. Somebody asked me about billing. Doctors like to bill using HCFA forms, things like that. You don't have to do that with most of this kind of stuff. When I started out, I had an Excel spreadsheet of how my clients—each client was assigned a number. So it was 1 was my first client, and 01 was their first invoice, 02 was their second invoice. I would just do a Word document, like literally, dear so-and-so, we did 14 physicals, here's how much you owe me. I give it to them. I email it to them, and they pay me. Now we use QuickBooks. It's easy, and if you know how to do that, it does it all for you. Contracting, a few observations here. Remember, I'm not a lawyer, I'm a doctor. A contract is really just an agreement between two parties, so try to keep it simple. We do it as simple as we can. So what are we going to do for you? When are we going to do it? How much are you going to pay me to do it, and how long do you have to pay me? 30 days. What results can you expect to get? When are you going to get them? We try to put in a cancellation clause that says, you know, if you cancel the contract, if you cancel a date, so we get paid, and there's some penalties in there. We do automatic renewals, if we can, and then we have a signature. It's really that simple. Beware of, you want to make sure you always have a minimum built in. A lot of times, like I said, they'll say, we've got 25 physicals, you're going to come out there, and 10 people show up. Well, somebody's got to pay me because you scheduled the fare to come to town. We came to town. You didn't provide your part. So make sure you have your minimums built in. Make sure you have your cancellations built in, because we've had several instances where they don't communicate. We show up, they're like, oh, not today. Yeah, today. We charge them usually half of what they would have paid us, and then we come out and we do it again in two weeks, and so we've made 50% more. Beware of the indemnity clauses. A lot of times, these contracts that you'll do with cities and things, they're written for road contractors and construction. They're not really written with medical in mind, and so they're really overly broad. So really try to tighten those down, if you can, to say, look, I agree. If I screw up, I'm responsible, and I will take care of anything that's directly due to my negligence or error. But I don't want to be responsible for your screw-ups. So when we had one we had to get out of that was—a city fired a guy that didn't want to take a physical, and they said, well, it's your fault. You came to town, and he didn't want to take your physical, so we had to fire him. We're like, yeah, I didn't tell you to fire him, but that cost us $20,000 to get out of. Yeah, so try to tighten those down, and that was a really overly broad one. So be cautious with that. So keeping costs low, remember, everything you spend is money you don't make. I think of these side hustles sort of like I think about gambling. I only gamble what I can afford to lose. Don't take on debt unless you have to, absolutely. Don't spend money you don't need to spend. When I was in North Carolina, the doctor across town built a new office. He was bragging to me how he spent $80,000 on his waiting room furniture, and I had just built my office, and I spent $2,000, and I recovered it for $1,000 because I bought all my stuff used. So his $80,000 chairs didn't make him any more money. He just spent that. If you're making a website, you can pay a designer thousands. You can do it yourself or have a friend or family member do it for hundreds. You can buy the fancy EKG machine for $5,000, or you can buy the Mac 1000 for $500 on eBay. Look for used medical equipment. You can get warrantied used medical equipment. Don't buy new stuff unless you absolutely have to. You don't need inexpensive phone systems or services like RingRx, Grasshopper, virtual fully-serviced virtual phone services. You can sublease space from other people. I've subleased from chiropractors and podiatrists and all kinds of people. And then if you do have your own space, you can always rent it out. Paul just popped his head in. I don't know if you saw that because he knew I was going to talk about lawyers. You may need a lawyer from time to time. There are legal services out there that will take a project and give you a project cost. Like you say, hey, look, I want to incorporate it in the state, I want to make sure I'm doing it correctly, I want to make sure I'm set up correctly. How much to do that versus it's $300, $500 an hour. And then when they do that to you, then it tends to expand, expand, expand. But if you can get them to commit to a project cost up front, do that. Watch out for your state laws regarding corporate practice of medicine in North Carolina. You need to make sure you're, you know, just make sure you're set up correctly initially if you do set up your own corporation. Watch out for your forms, your, you know, your GINA form, take your family history off there. Don't put that out there. Make sure you have your HIPAA stuff out there. You know, get, don't forget your insurance, get a good broker. Like I said, he may not be covered where you think you're covered. Keeping and losing business, always put your customer first, make them feel like they're important to communicate, deliver on what you say you're going to do. Be responsive. Make no requests, even the little ones. If you mess up, and you will admit it, you know, we screwed that up, you know, we didn't do the blood right, we, it didn't get to the lab core in time, it was all ruined, we had to do it again. They understand. As long as you own up, admit your mistakes. Build on success. If you do a good job, ask for references, ask for contacts, review a job at completion. Don't dismiss a one-off. It could be more opportunities. And try to master one or two things and do that a lot. Lastly, I just want to kind of leave you with a little story. Don't forget, it doesn't always work. Learn from the ones that don't work out. Don't be afraid to take another swing. When I was in Oklahoma finishing my training, I did a, I got a call from, I was working with this doc, and he was a really busy doc, really well-respected in the community, called me up. He said, he said, hey, Lance, come over after, after patients. I got something I want to talk to you about. And I called my girlfriend at the time, I said, you would not believe, I think this guy's going to offer me a job. This is great. So I go over to his office, and he sits me down, he goes, Lance, I want to talk to you about Amway. And I thought to myself, I'm not knocking Amway, maybe you can do great at that. But I thought to myself, here's this guy, he's a doctor, he's got the respect of the community, he's paid thousands of dollars for his degree, and he can't think of a better idea than, than Amway. So, so I'd encourage you, you know, you're doctors, you have powerful degrees, you have lots of experience, you know, take a chance, take a swing. His life's too short to be underpaid, overworked. So anyway, that's all I have. Dr. Peters, are you going to ask, or unmute for you? Yes. Can you hear me? I can. Can you hear me? I can hear you. I can hear you, yes, we can hear you. Thank you. I'm curious about the signing off on wellness routines, meaning that, you know, assigning authority for people to get the routine stuff. I did that once, and I found myself with 600 lipid profile results, all at the same time. So aside from the massive bolus of work that suddenly got injected, which, which I was happy to do, but it took a long time. I was wondering about the liability of it. Am I suddenly responsible for giving all these people cholesterol management advice? Yeah, I'm doing a medical conference, virtually. That's a pretty, that's a pretty intense time commitment. I'm sorry, I'm a bit stuttering because I'm hearing a lot of noise in the background, so it's kind of hard to talk correctly, sorry. Dr. Peters, I muted the other person, so maybe we could eliminate some of the background noise methodically here. Thank you. Go ahead, sir. Okay, I'm wondering specifically about signing off on, you know, the, the, excuse me, the wellness stuff. I did that once myself, and I was pleased because it generated a lot of business, but it was difficult to manage. I got literally 600 lipid profiles all at once. And it sort of suddenly hit me, what's my liability here? Am I responsible for giving these people, am I responsible for 600 individual counseling sessions? How do you handle that sudden bolus of work and the potential liability of, I mean, another example, they wanted me to do colon screening just, and they would take care of sending out the blood test cards and so on. But I didn't feel comfortable with that because I didn't want to, I didn't want, I didn't feel comfortable that two years later somebody was going to be diagnosed with a cancer that I had never gotten a screening test result on because there wasn't follow through, you know what I'm saying? I'm just wondering how you handled that. Yeah, so two things. On the wellness stuff, I try to be upfront that they're signing something that says they realize that this is a wellness screening, they're responsible for the results, that you're still probably responsible for any of the, and again, remember, I'm a doctor, not a lawyer, but you're still probably responsible for any of the critical values that might come back. And so what we do with those is I have staff that will adjudicate anything that's a critical value, just like we did for a positive COVID test. We were taking care of those. So setting the expectation up front that says, this is what I'm going to do, this is what I'm going to be responsible for. Other than that, you know, the expectation is probably you would give those lipid profiles back to the patient and say, it's your job to follow up on this. This is a wellness program, not a treatment. Thank you so much. Have you not gotten paid for some of them? And if you didn't get paid, like, what was the mistake? What do you mean, not gotten paid? Okay, good. No, I didn't know if you've had contracts and then they didn't come to get paid. No, I don't think, we had one where they said they weren't going to, they weren't going to honor the contract because the fire chief signed it and the city manager said the fire chief can't sign that. And they ended up paying us half of what they, and they never rescheduled. So, we just made money for doing nothing. Okay, great. Who's your biggest competitor? Would that be, is that Concentra? No, actually, pretty on-site stuff. Concentra, I don't know if they just don't do a lot of it or don't do it well. In the firefighter world, we have a few competitors, but we had one that came on the scene really fast, and then lately, after COVID, they haven't been able to do their jobs. They can't staff them, and so I'm getting a bunch of business all of a sudden. So, yeah, I don't, outside of the firefighter world, I don't really know. I guess there's probably some FAA docs that do 1,000 exams a year, maybe, but I don't look at them. Good question. When you were going back to, also the Amway example, going back to jobs, and which may or may not be a good fit. When I was, right after retiring, I'm looking for studying online, so looking at job opportunities. Two things, profitable and profitable, weight loss and medical marijuana, which had just become a thing in Ohio. Nope. Anyone have anything? Well, a comment. You know, chiropractor school, veterinary school, dental school, guess what they have in their curriculum? Business. Business. What do we have? Put it in your handkerchief, go out, and off you go. It's called business. They have one form of them, and then I'll have one of them in a while, so thank you. So, I do a lot of those kind of side hustles as well, and I've been doing that for a long time. I used to own my own health care company, and I still now, I think I have a federal employee, still in service, but I still keep those practices, those consulting jobs. So you're 100% correct. There's lots and lots of opportunities out there, and you can dabble and try them. If it's not for you, it's not for you. It's no big deal. There's no harm, no foul. And many, many times, what I do is I choose the ones that I have no direct patient-doctor-patient interaction with, no accountability, no liability. I keep my own medical malpractice on the side just for me, but I rarely have to invoke or use it. It only costs me hardly anything at all because I really don't have that kind of relationship anymore. And then the federal side, it's already paid for. So, what I do is when I contract with chiropractors and some other businesses out there, like nurse practitioners and physician assistants, if they need a DO or an MD to be the medical director, I contract directly with them. And since we were talking about money, I'm going to throw that out there as well. I usually charge per nurse practitioner anywhere between $2,000 and $3,000 per month per nurse practitioner approved. And that also, I am covered under that clinic's malpractices. They pay for it. So, that evidently deems my competition. That'll have to be the last question. So, there's lots of opportunities. Thank you.

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