Transcript:

Dr. T  0:52  
You guys. I can't even tell you how many times I'm trying to re record this episode to introduce to you a really special guest. And then I have my neighbor over here who decides to play a trombone at four o'clock in the afternoon. So if you hear it in the background, it's not intentional, but hopefully it goes away soon. So anyway, today's episode is incredibly special. I just got invigorated talking to Dr. Judith Borger. Dr. Borger is a mom of three wife, board certified physician, and successful business owner of both the aesthetic doctor and concierge medical arts. I can't even get to read all of her accomplishments. I'll put it in the show notes because it's also very important she coaches, she's done clinical trials, she's done peer reviews, she has opened a successful concierge medical arts practice. As an emergency medicine physician, I think that is just talent, upon talent upon of course, hard work. I'm not saying talent as if she didn't work hard for it. It's obvious. She's worked hard for her success. So check out the show notes for the details on her. But I want to share with you this conversation I had about how she started her concierge practice. And we had a discussion between what's concierge versus direct care. And listen, neither of us are word police's. You can call yourself whatever you want. You can build your practice however you want to. And once you start seeing the freedom of not working with insurance, you can literally do any job with joy, because it's going to be on your own time, you're going to have control in how you live your life and how you practice medicine. And that is the whole idea of my podcast is for you to pick and choose what you feel fits you. And like a buffet, I always have some kind of food analogy. So like a buffet pick and choose what you want, leave what you don't. And I hope you enjoy this conversation I have with Dr. Berger. Let's tune in. I want to welcome everybody here to the podcast today. I'm really excited to have a guest here in aesthetic medicine, which as a lot of us know, is a very profitable type of practice to even have you don't even have to go further into talking about what aesthetics is to know that's what everybody wants and are willing to pay for. So I want to invite you to welcome me, Dr. Judith Borger, who is a do and my husband is also a do so I am knowledgeable about the osteopathic path. And I know your knowledge and experiences is going to really help us understand how we can improve our private practice or even pivot into direct care. So welcome, Dr. Jude.

Dr. Borger  3:35  
Thank you so much for having me.

Dr. T  3:38  
I'm so glad that you're here because I have somebody question. I'm a podiatrist and none of the work that we do is considered aesthetic. It's not even covered in our malpractice insurance. And so this is going to be a new realm for a lot of podiatrists who are listening. But I also have MDS and DEOs, who are tuning in to see how they can expand their direct care practice a practice that doesn't work with insurance, where they can help people do the things that they love and get paid for it all at the same time. So could you give us a little bit of your background and how you got started in aesthetic medicine, and to where you are now?

Dr. Borger  4:13  
Yeah, absolutely. And, you know, I think esthetics even if you're not going to do it in a big room. It is definitely a great thing. And we can probably talk about that later, maybe not so much for podiatrists, but for more people that may be who knows, I mean, maybe people want to do their foot problems taken care of and get their Botox done at the same time. Who knows like right, I have no idea but a lot of you know people that do try direct primary care, you know, patients already trust you. And so anytime you can add sort of a profitable procedure that might not take that much overhead, but can expand your range of services or expand your per patient kind of spend, right it can be great for your direct care practice. So um, but more on that later. So I am an emergency medicine physician by training, which, of course means that I normally would be as far away from private practice as you could possibly find somebody. You know, I almost did dermatology Actually, I did a lot of rotations, I thought it was going to, that was what I was going to do. And then I kind of got a little bored. Because I did a lot of medical dermatology rotations and the rotations that I did were, you know, community dermatology was like rash, prescription rash, prescription rash, prescription rash prescription, I was like, I don't know that I want to do this for the next 40 years. And I realized that is not all dermatologists do. But like so many of us that are going through medicine, our like for six or eight week rotations really shape our view of the field, right. And so I did emergency medicine, which I totally, totally love. And probably like, and maybe you hear the story a lot, when you're sort of eight or so years out of fellowship, you've kind of gotten your feet that you've established yourself, like your job isn't that much of a learning curve anymore. And you kind of started thinking like, what else what next, and I realized that, you know, there was certain things that even though I love emergency medicine, I was really missing. And some of that was really the relationship with my patients. Because the sicker patient is in emergency medicine, the less time you spend with them. And I wanted that one on one relationship, and I was sort of missing using the creative side of my brain, because emergency medicine is very pathway driven. And then, you know, I still had always had a love. So even though I was emergency medicine person, I would go to these legacy conferences and, you know, listen to this stuff on dermatology. And so there was always that little kind of like, itch there. And then that was the time when I sort of took the jump and got certified and decided to do this as a side practice, which again, emergency medicines shift work. So it's really easy to not have to, you know, give up your whole job and, you know, be without an income, because we do shifts. And so there's always days off, there's always days during the week off that if you want to you can do something else. And actually a lot of I think shiftworker doctors, especially these days have some sort of a side gig,

Dr. T  7:30  
I love that you talked about what it was like to be in emergency medicine, because, you know, we all had to do emergency medicine rotations. And I think when you're young and inquisitive, and really high strung is exciting to do different rotation. But when we go into practice, we realize there are certain things that just don't run business as well. And I think emergency medicine is one of those things that really don't function well in a private practice setting. Because if you have a heart attack, you have to go you cannot just wait and go to a private practice office, you need to go to those facilities that have those resources. But then, I also see how you talk about pathways of medicine, where you you know exactly what you're supposed to order what you're supposed to look up and how you treat the patient and lacking that little bit of creativeness or even connection with your patients. So I can, that's exactly how I feel direct care works is the people who are looking to spend more to spend out of their pocket, they want that individualized attention, they want that level of expertise. And it's not to say that one is better than the other. I think there's just a place for everyone to pick and choose and adopt how they want to run their direct care practice. So you went into emergency medicine, and then you were going to these conferences, aesthetic conferences. When did you decide to open your own practice and say this is what I'm gonna do?

Dr. Borger  8:58  
It started gradually and I think that is also kind of maybe why my path is interesting is that you know, I started it was 2017 that I started a it actually still has the same name considers medical arts and it really started as a sort of mobile concierge kind of practice so I you know, what do I did rent a room from a salon and spa so I was suddenly saying you know if some of you are also thinking about how to do certain things, how do we start I mean, we all know that you know, when you start your own practice sometimes overhead can be huge thing and it can be scary thing to have to finance and rent and build out and all of these things. You know, I didn't do any of that. Right away. I really started with injectables. I started with Botox fillers, micro needling PRP, some chemical peels, and I would either do some truly concierge mobile services or While I did sublease a room from a salon and spa, to do aesthetic treatments. And so that's how I started in 2017.

Dr. T  10:10  
That's really good advice. Because I did the exact opposite. I took out a huge loan and built everything out. And then I regretted my five year lease on a property I can walk away from. So that is really sound advice to start small start with what you have and just be really gradual and probably being patient. I can't say on the most patient person when it comes to building a business, but long term goals of course, podiatry does have opportunity to do aesthetics, it just looks a little bit differently. I know podiatrist doing bunion surgery, hammertoe surgery, because of aesthetics, not necessarily functional, and there is a space for that. And I think direct care can work for that. So that sounds like everywhere else, you know, your face, especially people expect to pay cash versus other specialties where they assume the insurance will pay for it. So as you're building out your direct care practice, or you're calling it consumers, so when you call that concierge, does that also mean that you're billing insurance? Or is it just

Dr. Borger  11:05  
I don't say any insurance whatsoever, so nothing I do, you can pay with insurance for

Dr. T  11:11  
Okay, that's like a word that people get confused between direct care and concierge. When I first learned about concierge, it was exactly what you're doing. It's just high end stuff, you know that we know it's not covered by insurance. And there's a price tag with that. And then I started talking to other doctors who was who were a little bit more defensive about how you defined concierge where it meant you still bill insurance, but you have a retainer fee. And then I learned about direct care, which is really more of a social movement where you can have your price point on the low end on a high and you decide it doesn't matter what the price point is, the idea is just to be transparent and accessible. But we don't bill insurance at all. So how do you feel about those different definitions, if you will start to nitpick on like, how would you define concierge medicine? 

Dr. Borger  11:56  
You know, I actually considered monocle ours is the name of my practice. It does not mean that, you know, traditionally, I would agree with your you know, I just call my practice concierge medical RS because that's what it was it was I saw it as individual high end. You know, cash pay. And you're absolutely right that technically, it all falls on the direct care umbrella. And you're right that some of the concierge practices that I've seen, do exactly that you have, you know, a fee on top of the insurance payment. And I am not I don't I don't think I feel strongly enough about either definition to really have an argument with. And I know this was an argument, but to really sort of hear about what the different levels are because I don't think there's really a definition or is there?

Dr. T  12:48  
Yeah, there's no like association to police. What words you I'm on the same page. But ultimately, what we're trying to do is pull away from the I guess hamster wheel, as we call it, you know, trading your time for very little dollars for declining reimbursements. So the people who are listening are probably wondering, did you have a business coach or a mentor in developing your practice? How did you have the business savvy to know what you wanted to do? And how to make it profitable?

Dr. Borger  13:16  
Well, so I'm doesn't scratch other people now. Because I learned a lot of lessons. I think I'm gonna be really honest, I think I sort of jumped with both feet into the pool, and then was like, Oh, wait, I only know how to doggy pal. You know, so I think, you know, I did not have a business coach. You know, and a lot of the, like aesthetic boot camps, they give you like, a lunchtime lecture on business. And I think I did have a little bit of a background in accounting and numbers and things like that. So, you know, I had and taxes and I had, you know, I wasn't a stranger to that, but I had never run a business before. And I, you know, did not have a business coach, you know, when we're going to talk about what what I wish I would have done. That is definitely like, you know, one of the things I wish I would have done just a ton of work on a ton of training. And I coach a lot of other people on how to start a practice. But I kind of found that when I started, the people that I was surrounded by kind of the motto was to construct the opposite than me it was like get the $2 million loan, build out your location, get all these devices, and if you build it, they will come. And that's kind of what I was surrounded by. And I was like, Oh, that's not what I want to you know, I want to just start something small and grow it and so I think some of that was also that, you know, when you go to some of the conferences in the courses, a lot of the motto is very much that bigger and better. And I don't know if some of that is because there's so much industry sponsorship and the Obviously, I have a huge interest in selling you all the stuff. But no, I did not have a business coach and I did not really at the time really have access to anybody who said, Listen, you can build a life that or a business that fits your life. However, that business locks, right, you can build a business, if you want to not work at five days a week, what did I say, in this best world at the time was really like that one single business being built. And, you know, the best advice I got was, or the most common advice I got was like, You need more than a million dollars to start a practice.

Dr. T  15:39  
Yeah, I didn't take out a million, but I don't think I ever will. That's wild. Yeah, definitely you're you made a point about corporate industry sponsorship influence in how we build our practices. And I do think you can lose a lot of money. If you fall into the trap of you need to have everything before you start, or you need to line up all perfectly before you start not realizing that you're probably going to pivot as you go. Because you may not really know exactly what that vision is going to transpire into. And that's exactly how, when I started my practice, it was insurance base, I didn't think there was another way of practicing medicine. So how did you realize that you just were not going to work with insurance? Is it just in the nature of aesthetic? 

Dr. Borger  16:24  
Yeah, so the nature of aesthetics is really that you don't work with insurance? And And honestly, how did the level of complexity that I did not want? And even now, you know, I have people approaching me and said you did this than the other like you could take in? Oh, I don't want that. So I think the nature of statics, and then just the ease of it, right? Like, I mean, from a business perspective, it's so much easier, and you can set your price point, you don't have to clared with anybody, you don't have to go why and get like, you know, 10% back on that when the insurance company decides to reimburse, there's no silly rules about it. And you're right, there's this pricing transparency, right, you can say, this is what it's gonna cost. And that's the same for, you know, everybody, it's not like, Cigna negotiated this and Medicaid negotiated this. And by roll you can't like, there's none of that. So there's sort of a beauty in the simplicity of the dire care model,

Dr. T  17:26  
Did you have fears that it wouldn't work or other fears? When you're building out your practice?

Dr. Borger  17:33  
I honestly think that, you know, initially, I, because I started small, there really didn't seem to be that much at stake. I think the fears got bigger as my practice grow, to be honest, like, I had to do much more mindset work as my practice, you know, once you have employees and capital decisions get larger, I think there is this like fallacy that people are like, well, once I have a business that makes that much like, suddenly, all of your decisions just got so much bigger. So I actually, you know, didn't have fear starting, which is why I just started. But I think now that everything is more successful, and there's more to lose, and employees depend on you. And, you know, you're supposed to be on this trajectory model of growth and growth and growth, like, and there's always this next step. And the next step is always bigger, right? Like, I think the fears get bigger, too, and the decisions you make get bigger.

Dr. T  18:34  
So what is your current biggest challenge in your practice, now that you grow and expanded have experience under your belt

Dr. Borger  18:41  
I would say, and maybe some people can relate to that I think employees at the stage of the game really make or break your business, right? At least for me, you know, I have some wonderful employees. And then I just had to let go an employee and, you know, there's other ones that I would like to approve or that I, you know, have mapped out their growth, and they're just not wanting to grow at the same way that I would love for them to grow. So I would say, at this stage in my business, you know, a lot of the challenges are a lot of work, or a lot of thought I would say is employee based

Dr. T  19:18  
And what do you enjoy most about your concierge practice?

Dr. Borger  19:22  
What I enjoy most about it is the absolute creativity. I mean, what I love about entrepreneurship, and which is why I also love coaching other entrepreneurs. It's this whole idea that there are truly infinite possibilities and you can make your business whatever you want. You can pivot it every which grown, I think that's the most exciting thing, right? Like, yes, it can be scary when you're like, Oh, we're gonna do this and potentially, you know, suddenly there's a big price tag attached to gaining or losing it. But that's what I love about business. That's what I love about entrepreneurship, sort of like we had talked about that the you know that traditional way of medicine is so kind of clearly defined and in a way limiting, and a lot of us didn't know that there was a different way, suddenly you have this world where truly almost anything's possible, like you could tomorrow combined podiatry with I don't know what, and it could be crazy successful.

Dr. T  20:25  
I think that's what's intimidating is that because it could also be limitless? We're like, but what does it actually look like? Like, what does it look like on paper, so I can plan ahead, so I can project that I can be prepared. And I think the reality is, we can't prepare for everything, you just kind of have to embrace the ride that it is, and then you know, don't feel like you have to just get there, you really have to enjoy the journey as you grow, I think that's the biggest thing that I lost sight of is when I was building my practice is that it's always well, when I get there, then I will dot dot dot, right, when I hit this revenue, then I will be happy. But you're saying, when I get to that landmark, I have bigger problems to solve.

Dr. Borger  21:11  
And it's fun, right? Because your version of view is bigger, and you have a bigger capacity to hold and you have a bigger capacity to manage. And you have, you know, a bigger knowledge base and more experience. And I love that, you know, it's interesting, Martha Beck talks about sort of the stages of the human cycle, all at that stage of drying and scheming and coming up with light, what we're gonna do, and it is very anxiety provoking to some people who are more than people that like you, you know, would like to project it out and plan it out. So, you know, that's where we're all different. And so, you know, the, the jumping in, was not that hard for me.

Dr. T  21:53  
So what would you say to the person who might be interested in aesthetics? Where could they start to learn about it? If they don't have any background? in it?

Dr. Borger  22:03  
Yeah, I think the biggest advice I would do for people is there's a lot of training out there in like, how to actually inject and how to actually do the aesthetic procedures, and there's not that much business training, you know, and these are two very, very different skill sets, you know, I, and I see people that start and, and again, the, the industry and Instagram, and the world sort of tells you like, oh, you know, everybody in aesthetics is successful. But that's really not true. You know, like, everywhere else. I mean, among the people that I trained with, like that group of people will kind of stayed in contact for a while. And of course, there's social media, there's only two of us that still have practice as like, so many of them close, a band and one back rock. But there is also this pipe dream, or everybody thinks, Oh, everybody, anesthetics just make some money, but there is still a big business component to it. So you know, I have learned so much about business, I've, I've really, I think once I realized I really spend so much time and energy learning business and the business, not the statics and the business of running a practice. And I think I would just tell people that it's a totally separate skill set from statics you need both skill sets to be important. So whether it was by luck, or just enough sort of knowledge, or whatever, I was successful in my journey, and then I realized how much I had to learn. And I really dove deep and going to learn it. But if I was to do it again, I think I would. And I would tell new entrepreneurs, that really, that some of that, like thing that got sold to you about aesthetics is that you're going to be successful regardless, regardless of what you do is not true. And it's like in any practice, it's like in any business, like there's two different skill sets, there's the business skill set. And then there's the knowing how to inject into the treatments and all of that stuff. So I would highly recommend a mentor and I would highly recommend business coaching or some sort of business knowledge,

Dr. T  24:12  
For the person who's on the fence about leaving the insurance based practice and considering insurance pre practice concierge direct care, what would you say to them? 

Dr. Borger  24:22  
Oh, absolutely. I mean, there's so much freedom. There's so much fun. I mean, I I don't you know, that part I have never regretted and I love being in the space and it is, you know, it is so gratifying also to kind of build what you which to do. Right? And how do you feel about that?

Dr. T  24:44  
I love it. But there are definitely challenges because we're moving from a space of what everyone else has taught us. That this is how you do medicine. This is the way to do it. And we're moving against the grain of saying I don't want that. I want it If I want to build something for me, and I don't want to feel guilty or be wrong about my own dream, and so there's a little bit of a guilt or really just the fact that we don't know business and we haven't accepted that we're missing a huge component and building our practice, which is, our brand is building our own identity. So I feel like I kind of went in, they call it gaslighting these days, like we were told that this is just how it is you have to suck it up, you got to see 50 patients a day. This is what you signed up for. But we didn't sign up for this abuse, we didn't sign up to be told to how to chart how to code like that is not Doctor work. That is a administrative job. But now that I'm on the other side, it's obvious, it's obvious that what we've been conditioned to believe is a total fallacy just to keep us under their control right there as in the system as in never leaving, as in instilling fear so that we don't exit the system, because what would happen if all physicians woke up and was like, This is wrong, we should not be working with insurance, the system would collapse, right? So I do think that the system is set up in a way, I think it's factual that we see that the system does not want doctors to feel empowered, because what happens when we recognize something else will leave it. And I think doctors are just learning to wake up, especially through the pandemic, especially with social media showing us there are different ways to make income, it doesn't have to be stuck in clinical practice, or insurance based billing or any of those things. So it's nice to see that when you have the time to think about what you really want, you can actually get it and I think right through direct care, my belief on the whole scheme of thing. Well, I really want to thank you so much for your insight. I know I have so much to learn from you, not just from aesthetic, but the business side, that we never got to learn that people wanted to connect with you. How can they contact you?

Dr. Borger  26:50  
Yeah, thank you for asking. Yes. So um, you know, like I said, My brand is the aesthetic doctor. So it is the website is www.theaestheticdoctor.com I also have a podcast, The Aesthetic Doctor. And, you know, I do just like what you said in your intro, I do courses, I do coaching, I do podcasting. And then I have my now very successful practice, that I'm also running my why. And I think that's really what I kind of help people do when I work with them is figure out what kind of a practice do they want? Because sort of like this entrepreneurship gives us this flexibility. I want your business to make your life better. I don't want to add another source of hustle and stress. Yes, we have to work hard. And at the same time, I really believe in building businesses that work for your life. And that means like all aspects of your life.

Dr. T  27:49  
Where were you when we were in school? Why are we just learning this now? Well, thank you so much for being with me today. I'm gonna put all your information down in the show notes so people can connect with you. And if you're listening, thank you so much for being here. I hope you were really intrigued about aesthetic medicine. And if you have any comments, please send me a note. I'd love to hear about it. And I will catch you next time. Thanks so much for being with me. Take care.