Hello Don here, welcome to Podiatry Practice Mastery. We're helping you get your practice to the $1,000,000 mark and beyond. This is going to be a recording of a Friday with my patients. So just a reminder, Friday is the half day that I do routine care for the first half of the day and then the second-half I just see see normal patients.
So I, I don't spend too much time on the routine care aspect and I want to spend some time talking about Shockwave because I'm getting some, some questions from people and some other doctors and, and I've been dealing with certain issues with patients. I want to talk a little bit about expectations. I'm going to start with with Shockwave first. So I, I saw a couple of patients in the afternoon for Shockwave. One of them was a 59 year old man. He had left Achilles tendonitis.
He had six sessions of Shockwave. He really had no pain at all to the insertion of the Achilles, but he still had tightness and this isn't an interesting topic of expectation so I maybe I wasn't clear enough, but like when there's no pain and they're just tightness, I'm fine with that. He wanted to help break up some of that tightness and had already done PT so I recommended a washer tool, which is like a self grass tuning tool that he could use on his own. So that was 1.
So I just spent some time talking about the expectations of what, what, what this patient should have and what they should expect with this. There was another patient that was #5 out of 6 of Shockwave for plantar fasciitis. He was a gentleman that he had a little bit more pain, but he also biked 3 times this last week and, and was kind of in a, in a hilly area when he was biking.
And so I once again, I talked about expectations about, OK, I know you're not totally out of pain in your plantar fascia, but you may have done too much activity and just made things tighter. So I just reinforced the importance of doing the foam rolling, night splint, morning stretch. And he wasn't doing that that well. But I think the main issue was he was just too, too active with that one. And then the last patient, this was a patient I picked up with a
colleague of mine. She came in, she had previously had four sessions of Shockwave by one of my colleagues and she was really kind of frustrated about what was going on because she wasn't feeling any better. So let me just explain. So she had insertional Achilles tendonitis and it was bilaterally and they did 4 sessions and now we are, we're about 8 weeks follow up. So there it wasn't even the I don't know why there wasn't a six week follow up.
Maybe she missed it. She made an 8 week follow up and she was assuming that everything would be better by the 8th week. I I find actually one of the most challenging areas are where the tendon inserts into the bone. So this could be like the nevicular tuberosity. So the posterior tibial tendonitis word inserts there and also insertional Achilles tendonitis. And so these ones I tell and I think it was expectations. I say, you know, I expect maybe 20 to 30% better at at 6 to 8
weeks and then I double that. So I usually do six week follow up and then a twelve week follow up and and then they're usually much better, but it just takes more time for them. So I really kind of talked her off the ledge and and I also just because she was so kind of nervous and things like that, I said, I just reassured her. I'm like, what else are we going
to do? We're going to, we're not going to reattach your Achilles. We're not going to detach and reattach it doing like a speed bridge procedure. And I did another session of Shockwave for her, like for without charge. I typically would have done 6 sessions. I know my colleague does 4. I just find sometimes find that 4 or even 3, which is kind of the norm, isn't enough when you're dealing with the insertional aspect. It just takes maybe 4 is enough, but you just need to wait longer.
So I just kind of reassured her and I'm going to see her back in two months. So those were kind of the things with the shockwave. I think expectations are a big thing when you're talking with patients, especially when you're starting out. And this can be an area that can be a challenge because if you're not confident enough in the, in the, in the technology and how you're using it, you're going to, you're going to get spooked at about six weeks.
Would not everyone is 100% better, but people aren't 100% better at six weeks. But then that continues to improve over time. And so for this one, like I said, I did do the shockwave. It took me extra time. I didn't charge them, maybe I should have, but she was just kind of one of those patients that was kind of spooked about about everything. So I guess the, the main word for this is be careful of the expectations and be very clear where patients are going to be at, at the last visit.
And that's where I use this shockwave last visit sheet. So I have a sheet that actually give them at the last visit and it says, OK, I expect you to be, you know, 20 to 50% better at six weeks. This is what we're going to possibly do next. So they kind of know the plan of care because this patient didn't know anything about the plan of care that was going to be next for her. OK, let's go into the day. There was just some of the stuff for the routine. There was a patient that was an
80 year old female. She had a right hallux kind of a onycholytic nail with a pyogenic granuloma underneath that area. So I numbed up the toe, kind of divided back the toenail, saw the pyogenic granuloma and took a pathology and I kind of divided almost like an ulcer that was there. So I documented as an ulcer and A and a nail evulsion and I sent that to pathology just to be on the safe side to make sure it wasn't anything else. But it looked like a, a pyogenic
granuloma. Next was a this was a shockwave of one of my colleagues. He was, he called out today. So beyond doing all of my routine care, I had to see a couple of his patients as well. And I didn't have a nail tech today. So Marjorie took a day off. I think it's good. I always encourage people to take days off, but it, it makes it a little bit easier. But it, it actually gives me also more rooms to, to, to treat with. So I have six treatment rooms
all by myself. So it makes it a little bit easier that way. So that was a Achilles #3 out of four for the, for this patient. So they, some of my colleagues don't do 6 treatments, so they did 4. Next was a 67 year old female for right post op. She had a second toe fracture fragment at the base of the 2nd digit, kind of a weird fracture that was evolved or that was pulled out during the surgery. And I put her in a Cam boot. So you know, global post op period got the X-rays and I and
I was able to do the Cam boot. And this is a conversation I had with, with one of my colleagues the other day and this other doctor that that's starting with us. I just encouraged him because I think a lot of times we leave, we leave, I guess we, I guess you could say we leave money on the table and, and meaning, you know, we get them a surgical shoe when you do the surgery. And then usually at the post op,
you get a Cam boot. But if you forget that, if you forget the Cam boot, then you're, you're leaving that revenue on the table. So it's something that is going to be beneficial for you. OK to to every post op gets a Cam boot basically that's that's the way I do it. OK next patient was there's a diabetic foot exam 78 year old that had onychomycosis and I recommended formula seven. I don't do that a ton, but like in older people, a lot of times
I, I do that. And then there was a also another, another patient that was a self pay nail care, divided the nail and they had warts. So they had warts. So I did kanthurdin for this patient. And so when I made the follow-ups, I made a couple of follow-ups. I think this is another point is like making multiple follow-ups for patients. So they're going to do one month wart, 2 month wart and a three month nail care. So I, I pre booked these wart treatments so they can get in
the schedule. And those are so you can just do, do those that are, that are needed for the patients. I think sometimes we only do them a month at a time or something like that, But you have to have clear expectations. What's really helped me is my this wart treatment sheet. So if you don't have it, shoot me an e-mail. I'll be happy to send you my treatment sheets. Don at Podiatry practice mastery.com. The treatment sheets with the wart one, I, I, I basically just
put it on a, on a paper. What's it called? Like a, so where you fill out the paper, the, it's slipping my mind right now. It holds the paper. So I just put that on a clipboard. I put on a clipboard and I, and I do it in front of the patients. And I, and it clearly explains like the benefits of Swift, the benefits of canthrodin, benefits of laser, the benefits of salicylic and other things like that. And it makes it really easy for
patients to decide. And that's how most of my patients, when they do decide to do Swift, they do it based on, on that. So that was the morning, the afternoon there was some reason some of my nails are getting in my afternoon. I'm not exactly sure. I think it's because of my staff that are scheduling them. But the first was a 75 year old man had nails and he also had a contusion of the toe with black and blue. So there was an office visit for that.
Next was a 56 year old that had a fourth toe ulcer. We did X-rays and he has osteo to the tip of the toe was being seen by one of my other colleagues and I was, this is I was filling in for my buddy, my other doctors here. And so he was put on doxycycline and he's going to have a distal
amputation of that fourth toe. Next was a left 35 year old female for a left hallux wart and she this was one that was kind of an issue was seen by one of my other colleagues and she had canthered in, but the thing blistered up like no one's business. The thing was huge, huge blister and I think it was the new formulation of the canthren that we got and she only left it on six hours and then she washed it up, but there's like a huge blister.
And so I did not do canthren and I did topical salicylic acid. I just want that all that tissue just left off to see what's underneath there. It was hard to see anything for that patient. Next was a 63 year old female had a callus on the distal tip of the toe. So I did a Crest pad for her and I did an office visit for the for the hammer toe, talking about surgery if needed.
And next patient was a 59 year old with a right hallux fracture follow up at the tip of the toe doing much better from the fracture has some metatarsalgia on the other foot. And so we were treating that and we did an office visit for that because it was a new diagnosis. It didn't relate to the fracture and we did an office visit for that. So even though we're in the global for the fracture, you could do a new office visit because it was a new condition
for the other foot. Next was this is a 18 year old female that had bilateral warts. She has had them for multiple years, came with her parents. She's in studying in college year and this is where I use my work treatment sheet. I just laid it out and they decided to do swift. They did number one out of four for those warts.
She tolerated it well. I find that Swift is quite painful and I actually had someone asked me the other day if you could, if you were just starting out and if you could choose between like shockwave and swift, which would you choose? In my opinion, even if you can see the patients that I'm seeing here, I would do shockwave or actually they said shockwave or laser for fungal nails or swift. I would do shockwave #1 and swift #2. I have a couple of lasers for nail fungus.
I wish I could say that they worked great. If you are a person that gets great results, let me know. I'd love to hear it. But I would do Shockwave all day long first and an ultrasound all day long if you're starting out. Next patient was a patient with a rash on the right foot with nail thickening. This patient had done well with Diflucan in the past. I find Diflucan works really well. Like some of these nails that are really brittle and they're, they're, they don't respond to
trybenafin. Like it's amazing what it can do with some of these these bad nails. Like she is really a believer and she had to kind of some changes in the base of the nail was just paranoid. And so I, I gave her another round of Diflucan and also for a rash on her foot, I gave her ketoconazole. Next patient was a orthotic check, a one year orthotic check, 70 year old female. And I also, she also had some
nails that she wanted done. So I did that in a callus that so the nails were covered because they're thick, but the callus wasn't. So she charged 75, she paid 75 for that. Now these one year orthotic checks, when I was first starting out, I, I was always trained or I remember learning at the AAPM to always have like
orthotic one year follow-ups. And I think if you're starting out and you're not as busy, I think it makes sense to see them to see everyone back as is. It depends if you have a supply problem or demand problem. Meaning if you, if you have a supply problem, you, you, you don't have enough supply, you don't have enough of you to go around, so you don't have them
come back as often. So I'm, I'm, I'm at a phase where I'm not having these orthotics come back every year because it's a low level visit and there's not usually much else in terms of billing that goes with it. If you have a demand problem, like not enough demand for your services, like you're starting out, you're going to have everyone come back because you just need the, you need the bodies and the chairs to do that.
And I've, I've talked multiple times about that, but this is 1 where I used to have them do it every year. I, I am thinking against that because I'm not really doing much and in the level of the visit doesn't really condone having them come back. I guess one way around that is if you had like, let's say a double booked 10 minute slot, you could theoretically see them in that time because they're kind of going to be simple, simple visits.
Next is a 75 year old female for a right carry flex and she got a kit and she had callous care. So she had to pay cash for the calluses carry flex in the kit. I think it's $200.00. So it's, it's, it's decent in terms of reimbursement. I would really love to figure out how to get all these carry flexes that I've been doing on my nail tech schedule. I, I haven't quite figured out how to do that. Probably it's me just being too nice and having them not know
where to schedule them. But I think patients will be flexible if they want that procedure to put it in my, in my nail nail tech schedule. So once again, if you want these things, let me know what I'm working on these days. If you want to know, besides the challenge, I'm working on this challenge that I'm, I'm excited to, to, to meet with people and we're going to have a mastermind to help you get your practice to the $1,000,000 mark. I think that is great benefit.
Certainly if you're just starting out, I would just do the practice Mastery Academy. It's real inexpensive. But if you want a little bit more one-on-one contact, we're doing that. And I'm, I'm working on something called LTV and CAC. So lifetime value of the patient and then the cost to acquire a customer. So I'm, I'm, I'm struggling right now with ad attribution.
So what that means is I'm trying to determine like how beneficial my Facebook ads are and my Google ads are in terms of getting patients in the office and then equating that to revenue. So I can see how much I can, how much more, how much more I can invest into that. So that's something that I'm working on right now. I'm, if you, these are all on my spreadsheet. I have the spreadsheet like I'm how to calculate benefit to Shockwave for Swift for your EMR.
And now I have this, I'm adding a new column for this CAC ratio, the cost to acquire a customer and kind of how I'm figuring out these calculations. This is all in an Excel spreadsheet. So once again, if you, if you, if you want this, this would benefit you certainly shoot me an e-mail down at Podiatry Practice Mastery. Happy to share this with you. This is these are the types of things we're going to kind of go on in this, in this mastermind.
I know sometimes it's hard to do things on our own. That's why I think these these masterminds can be beneficial. So if you're interested, let me know and we'll talk to you tomorrow.