What's the easiest way to do a skin biopsy in the office? I frequently talk to doctors and and they say really, I don't have any time and I practice to do biopsies. It's too kind of complex. I think the, the reason we don't do things in our office is because they're they're complex and there is no easy system. I'm a real big systems person. I think systems make things a lot easier. And I want to explain a little bit of my workflow for biopsies.
I'm doing this in a couple of first couple of reasons. One is because I'm going to be doing a lecture at a upcoming APMA meeting or not APMA, but one of our like mass APMA meetings about biopsies. And I just hear that, like someone said, like with our Rep anyway, who looks at my biopsy because I do a lot more than others and I don't feel like I do a lot more. And I had one of the doctors in our office actually sent me a patient to do a biopsy on today.
And I'm like, this seems so, so easy. So let me let me talk you through what what I do. So first of all would be like the room prep. So all of my rooms on the bottom drawer, they have like specimen bags and they have those little formaldehyde filled little containers. I don't know if it's saline or formaldehyde. I think it's, I think it's formaldehyde little containers. And then they have 2mm punch biopsies. So that's really it. 99% of the time that's what I'm using and my process.
So for example, there was a patient that came in today that needed a biopsy and one of my colleagues sent sent them over for the biopsy. But even if they didn't, so the, the process is like if I see if someone needs a biopsy, I have a little button in my, in my room. So I click the button or I open the door and that triggers my staff. They come in and say I'm going to do a biopsy.
And then what that triggers to my staff is that I need one CC of Lyta with EPI and I need a consent for a biopsy and that's about it. And they do them when they do the, the lidocaine first and then they do the consent second. The reason they do that is so I can do the lidocaine, have it numbed up, and then they come and get consent and then I can do it. I do it all when I'm sitting
there. So literally it takes like 30 seconds to numb them because I just do a little wheel underneath the lesion and then I take that 2mm punch. I do one punch and I'll take a little tissue number, cut that out, second punch, pull it out, put some gauze in a Band-Aid and I'm done. And then my staff, if they haven't got consent, they'll come in and get consent.
So it's really the most concise way to do biopsies that I know of. And it literally takes me like 10 seconds to say that to my staff, 10 seconds to numb them, and maybe 10 seconds to do the biopsy. So it really doesn't take that long. It doesn't really add anything. They don't have to come back. The only ones I would have them come back for would be like nail matrix biopsies. Those can be a little bit more time consuming and I like to plan those.
But and also nail sample biopsies are really easy. I just take a little clipping of the distal nail. I don't call that a nail biopsy. I just call it like a nail pathology sample. When I do an actual biopsy, it's usually for like a Milano Nikki or something I'm concerned of in the toenail. So that's how I do it. I'd love to know what other people do or why you're not doing it. It's pretty easy to do as long as the staff knows what's going on.
OK, so let's go into this day. This is a recording from a Tuesday in the office. First patient, 63 year old man, right plantar fasciitis. He's 50% better. I don't need to see him back because he is he is feeling better. So he's 50 or probably a little bit more. Next was a 62 year old female had right carry flex. She actually came in from a referral from one of my colleagues wanting carry flex, but actually I think she benefited from Onifix better.
So carry flex by the way, is that fake toenail you put on that makes it look good? Onifix is for ingrown toenails. Now I'm using this a little bit off label I find with some patients with onycholytic nails. I trim back the nail and I apply it at the base. So I find that a lot of times nails get thicker because there's micro movement. So when they're oncolytic or detached, they they move more and then they get thicker to kind of mitigate that extra movement and to make it more stable.
So I think by putting the Onifix, which is like this little resin that I put on the nail that like it's like a speed bump and I put that on there and then it's kind of stabilizes it as if it was a multiple layered nail that stabilizes it as it grows out. Sometimes it can help it to reattach, but this is actually one of the more challenging things that I treat, getting nails to reattach and I'm not that good at it, but I that sometimes works for some of my
patients. OK, next patient was a 49 year old man. He had left plantar fasciitis with Aquinas. He got my Pelto special which is the night splint foam rolling in morning stretch and he also got Meloxicam and I'm going to see him back in four weeks for an ultrasound. Impossible shockwave. Next was a 56 year old female for bilateral foot pain. She this is kind of a challenging one.
She has these weird pains and she requested PT today and requested disability and I don't do a lot of disability like short term disability. But she had to come back again today requested that and I gave her PT So I'm going to see her back after two months. Next was a 59 year old female for left foot fracture. She has pain that continues so I ordered an MRI after having her in a Cam boot. So I'm going to see her back after the MRI. Next was a 62 year old male for a diabetic foot exam.
I did that that was a those really tend to be lower Level 3 visits and I'm going to see him back in one year. Next was a 60 year old female for right second Med head pain. She got meloxicam and if it's not better at the next visit, so possible like capsulitis, I'm going to see her back. She's going to do contrast baths, meloxicam in different
shoes. I'm going to see her back if it if it's not if it's hurting continues to hurt, I'm going to get an ultrasound but I did not make a follow up for her. Next was a 77 year old man had a right lateral hallux avulsion and, and he also wanted nail care and I'm not going to actually, he wanted to be back for three months for, for nail care. So I'm going to be him back in my nail care time Friday mornings. Next was a 53 year old man for a left lateral foot biopsy.
That's the one I just talked about or for one of my colleagues here. Next was a 80 year old female for this was kind of a, this is a good patient. So she had right midfoot arthritis. I got X-ray, I got ultrasound, I did a ultrasound guided cortisone injection to two of her joints, the second MC joint and then avicular cuneiform joint.
And then I talked to her about gapped lacing and I scanned her for orthotics and I talked to her potentially in the future to do shockwave for the bone marrow oedema. Once again, doesn't help with the arthritis, but sometimes can help mitigate the symptoms if the orthotics aren't sufficient. I'm going to see her back in two months. So that was a good patient because of the orthotics. Next patient was an MRI 68 year old female MRI follow up for
plantar fasciitis. She had a lot of things that are MRI reviewed that. Now one little tip, this is what I tend to do. I tend to review X-rays before I see the patient. I review MRI's before I see the patient and I don't always show them the X-rays or the MRI's. Sometimes they do, but a lot of times the patients don't know what I'm looking at and they don't understand and they get confused and it'll ask me what those two little dots are underneath the big toe, the sesmoids.
And so but for this one I did go over the report a little bit and I gave her as well a couple of injections because of the midfoot arthritis she had. She also had a midfoot arthritic joint and I did 2 Cortisones and due to the pain and the arthritis I put her in a Cam boot. So I did some DME for her. I'm going to see her in one month. Next was a 53 year old man for left Hallux Limidus. I talked to him mostly about shoe gear because I think it was more of a shoe issue that was
irritating him. I'm not going to see him back. Got X-rays and things like that. Next was a this was an MVP patient. So let me tell you about this. This was a Medicare patient that has mass health. So these ones, they Medicare pays 80% mass health. The patient opts to pay for 20% because we don't take mass health, which is like Medicaid bilateral foot pain, bilateral plantar fasciitis, bilateral aquinus. So they got foam rolling night splints bilaterally and then a
morning stretch. And this patient we talked about doing either cortisone or shockwave if they're not better in about four weeks. So it was good because of the bilateral night splints. Now I frequently do. If they have bilateral symptoms, I'll do bilateral night splints. In the past what I used to do is I say OK, we're at one night one side, one night the other side. But I have no issues with insurance covering 2 of them so I tend to get them too.
Next patient was a 46 year old with bilateral Achilles tendonitis. So I did bilateral shockwave #3 out of 6. She was really kind of concerned so I had to spend a lot of time just calming her down. I think insertional Achilles tendonitis is one of the more challenging things I treat with shockwave, but she tolerated it well and she is seeing some progress. Next was a 40 year old man for a right matrixectomy on the lateral side and she he also did the kit.
So one thing I've learned for a couple of things, I can depend on my staff and I think they do a good job at explaining like why they need an even up with their with every single walking boot. Like the even up is that thing that you strap on the shoe. So that adds an additional $30 or why they need the Amerigel kit. Every time I do a matrixectomy that's adds another like $60.00.
So, but I find that if I present it to the patients and then hand it off to the staff just to fulfill it, it works a lot better than them coming in and having to explain it. I find a lot of times the, the staff have a challenge with doing that. So I find helping it helps them if I prepare them, prepare this patient for that. Next was a 69 year old man. He had 4 swift treatments and here he's back for his three month follow up and he is
feeling much better. And so I got a box of tips out of that one because I did a, a YouTube short for that patient. So just so you know, if you do swift and you do short videos and you send it to them, they will give you AI think a box of tips or at 1 tip or I don't know how much tips, but that's what they'll do next was a 18 year old man that had he had Down syndrome. So he had bilateral pest planus, posterior tibial tendon dysfunction, athlete's foot and
nail fungus. So he got, I sent him to hanger because once again he has Medicaid and no I'm sorry, Blue Cross and I can't do AFOS. So he's going to get bilateral wishy braces from hanger. Unfortunately I can't do those. And then he's going to get the Pelto special for fungus, which is he's going to get tribenafin and he is going to get LFTS. He's going to get the UV light and shoe spray and the biotin. OK next patient was a 75 year old female for right ankle
sprain. Follow up her sprain was feeling better. She had a ATFL issue and now she had some pain in the sinus tarsi. So I did a cortisone injection in sinus tarsi and this was all after her PT. She's going to transition down from the ankle brace into more of like a neoprene base and then she'll follow up as needed. She originally had an ankle brace dispensed. 39 year old female next for wart that had kanthridin. She's on #4 I think of this
kanthridin treatment. Next was a 41 year old female for left second met fracture. This was another MVP because she had a second met fracture. I gave her meloxicam like I do for most patients. I dispensed a Cam boot and I used fracture care for this patient.
So a fracture care, yes, there's a 90 D global, but I'm going to see her back in four weeks and hopefully that'll be it for the follow up. Next was a 48 year old man for right shockwave #4 out of 6 he has on the MRI he had some bone marrow edema around the subtalar joint region and I did a focused shockwave there and then the radial shockwave on the peroneals. And then the last patient of the day was a 61 year old man. His Now this is a, this is a challenging 1. He got new orthotics.
He had done well with his old orthotics for nine years and developed plantar fasciitis again and I got him the orthotics. I did bilateral cortisone injections because he's a butcher and he owns his own butcher shop so he can't take time off of work. He didn't have much improvement with the with the cortisone injections and I was a little paranoid because when I saw him, he wasn't getting better. And I always get a little concerned when they when they get new orthotics.
And I was like, yeah, I use the same company. And so usually I use forward motion. And then, but in this case, he previously had Northwest. So I ordered NW orthotics just to make him just like the other ones. And then it kind of dawned upon me and this is a kind of mistake I made a lot in the past. So I want to, I want to share this with everyone. Patients, if they get orthotics too soon when they have plantar fasciitis, the orthotics don't feel good. And I know this is kind of obvious.
That's why when I see a patient for plantar fasciitis, I don't tend to scan them the first visit. I do it when I'm doing shockwave. I'll do it the third visit because hopefully by the time they come in at the 6th week where they get in the 6th shockwave, they'll start. They're actually already starting to feel better because if you have plantar fasciitis, nothing is going to feel good. Like no orthotic, in my opinion, is going to really feel good. It doesn't do a great job at
taking down the pain. It does a really good job at kind of offloading the fascia to help it prevent it from coming back. So for him, I said, hey, you know, you're going to, you're going to, you know, I would, you know, it's nine years after you had it. Before he had thickening of the fascia, I gave him options of doing cortisone injections. This would be cortisone #2 on bilateral heels, or you could do Shockwave.
And I said, you know, with the thickness of the fascia, I really think shockwave would be the best. And so this is kind of a challenge, I think, for some people and for me actually, too. But let me explain how I do it. So, so bilateral shockwave for six sessions ends up for me to be about $3000. And that can be a big, a big, a big value, a big amount. And for him, I, I basically said, you know, I know it's hard for you to get here because of
time. So I was willing to see him first patient so we could open up a store or even a little bit before first patient at 8:00 AM for the six visits. And then I also said, you know, it's for the six sessions, it's bilaterally. So usually for one side, it's 2:50. So two sides is 500 per per session. So that's 3000 and, and, and he was aware and, and I, and I, and how I kind of explained, I said, you know, the 3000 isn't usually the problem. The problem is getting your butt here 6 times.
And that's really true. I think for people that have a good job and that have their own business, it's not the 3000 because there is, I always say the 2082 to 85% success rate, it speeds up the healing by 50%. That's how I explained Shockwave. It's more getting there six times. So I try to make it as easy as possible for him to get to get into the office. OK, so that was the day once again, I hope you guys found
this beneficial. I am putting together a challenge, 6 month challenge for a group of doctors, a kind of a select group that want to help get their practice to the $1,000,000 mark. I want to be clear, this is going to be more for doctors. This has been thinking about this more for ones that are probably in the six or 700 realm wanting to get to the $1,000,000 mark. That's a little bit easier because if you're under that amount, you're probably not busy enough.
Then if you're not busy enough, you might have a hard time paying for it. But also you just need to work more on marketing. As I've mentioned before, there is either a, some this isn't, this isn't my idea. I'm stealing this from Alex Harmozzi, but there's either a supply issue or a demand issue. And it's a lot easier to deal with a with a demand problem, I'm sorry, with a supply problem
than a demand. So demand problem, meaning there is not enough demand and you have to really just if there's a demand problem in your practice and you're not busy enough and you have open slots, you have to do everything you can to fill those up and that you have to learn. So my favorite book for that is going to be $1,000,000 offers and $1,000,000 leads. OK, so $1,000,000 leads will help you to kind of fill that up. I do have information also my practice Mastery Academy about
all of that. But then once you have the demand filled in your, all your slots are filled, then you then you have a supply problem, meaning you don't have enough supply, you have too much demand and not enough supply. And then what you do is you optimize. So that's where you have to do all these other things to make your, your practice more profitable. And that's where I think my sweet spot is, is helping you get your time back and doing it more profitable.
So that's what we're going to talk about in this in this challenge. So if you're interested, go to podiatrypracticemastery.com/challenge or you can shoot me an e-mail. I'd love to share more about it. OK, Don at Podiatry practice mastery.com. Thanks. See you tomorrow.