IOF Max Experience ReCap ( PRP-Now Ask Me Anything )

Let’s dive deep into effective treatment strategies and cutting-edge procedures, prioritizing holistic patient care every step of the way. It’s not just about optimizing treatments – it’s about revolutionizing clinic operations with streamlined workflows and efficient communication channels.
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Seize the opportunity to learn a different and comprehensive framework of effective treatments, procedural excellence, and guiding clinics towards sustained success in the ever-evolving healthcare landscape
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Website: businessoforthobiologics.com
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Transcript

Intro
Hey, I'm Dr. Ariana Demers. I'm an orthopedic sports medicine surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the Gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective, but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for health. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on the value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.
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Dr. Ariana
All right. How's your clinic going? How are things?
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Dr. McGee
So good. So today, raise the price. Nothing. No. Not even like a blink.
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Dr. Ariana
No one even cared.
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Dr. McGee
Like, oh. So I went from 1,950 to 2,750 for PRP, single injection.
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Dr. Ariana
Yes.
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Dr. McGee
The response was like, oh, okay. Can we do that today?
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Dr. Ariana
And then you kick yourself and you're like, oh, my God. I've been throwing money away. Crap. I've been leaving money on the table. It's just been sitting there waiting for me to ask for--
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Dr. McGee
You have to go through this, though.
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Dr. Ariana
I know.
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Dr. McGee
I feel.
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Dr. Ariana
 I know. I told you, I've been raising my prices for an entire year.
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Dr. McGee
Looking back, do you honestly think you could have gone like well, I used to charge $900. Now I'm going to go $3500. You yourself mentally. I couldn't. I just couldn't do it.
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Dr. Ariana
No, because you have to get that experience where it actually happens and it's working and you're like, oh, nothing happened. And then you raise it a little bit more and you're like, huh, not one thing happened. Okay, let's do this. ​ Right? You have to have those successes. Then just like Ateba was talking about when you were talking about staffing, right, so you coach up to the highest, and then that's the baseline. And then you coach up to the next level, and then you just raise the baseline. And you're like, okay. Because in your mind, it wasn't even possible that you could charge 2,700, right?
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Dr. McGee
I think also thinking about it, adding some of those other little things to the offering where you're not totally chunking out that new amount that would be your profit, but making it like, okay, I'm providing more stuff. I don't know. For me, that just feels a little better.
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Dr. Ariana
Yeah, because you feel like you're providing value, right?
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Dr. McGee
Yeah. And also adding to things that are going to help it feel better. So whatever it is you're talking about.
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Dr. Ariana
Totally. Yeah. No, you're not wrong. But it's a psychological problem, and the patient didn't blink. And I think, honestly, it's so hard for us to wrap our minds around that people want the thing that is more expensive because it's better, right?
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Dr. McGee
Well, they want you to guide them to what's going to help them get better. They're really not considering that. That's not the thing holding them back. What holds them back is if you can't really help them understand why it's good, why it's going to help, or that there's evidence showing that that's what's actually going to lead to.
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Dr. Ariana
Right.
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Dr. McGee
I think that's what-- they just want to hear like why do you think it's good enough for me to do that? If you understand it, can explain it, and now enough times of like, I'm seeing these patients back. They're happy. Nobody is unhappy that they did it. You can explain that without just saying it that way, but being able to say what they're going to get out of it, I think that's the thing. If you can help them understand the value, then they're fine with it. If you're like, It's pretty good. Give me three grand. They're like, I don't think so.
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Dr. Ariana
No, But if you truly believe that this is the best way for them to solve their problem, to get the solution that they're looking for, you can even say it that way. And I think thinking about it-- I forget who I was talking about. If it was free, if money was no issue, you were choosing A, B, or C, and it was all free, what was the best thing that you would suggest?
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Dr. McGee
It's 100% certainty you would choose this. You would use biologics as part of your game plan. Whether it was with or without surgery, you would include-- I've been saying that to people for years. My term was if it was all five bucks.
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Dr. Ariana
Absolutely. If it all cost the same and it was all $5 and-- that was not an issue. I use it like if you were my family, I would recommend this. I think it's the best.
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Dr. McGee
It was my shoulder.
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Dr. Ariana
Yeah. You can use any of those because it's true, right? You have to-- in order to fully sound and for them to hear the authenticity of what you're saying, that you truly 100% believe it, and you have to believe it, use those phrases that are actually true, right? Yeah. Good job. That's amazing. Anything, any other wins in your clinic?
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Dr. McGee
Well, like I said, we had three or four-- we did four today.
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Dr. Ariana
Nice.
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Dr. McGee
And then scheduled three more.
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Dr. Ariana
Very nice.
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Dr. McGee
Then there's a couple more that are having to have surgery, but that will do it with surgery.
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Dr. Ariana
Nice. How's your staffing situation going?
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Dr. McGee
I have to get a certified X-ray tech because we're getting a fixed X-ray unit.
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Dr. Ariana
Okay.
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Dr. McGee
Installed. I've been getting by with a portable, and I think I've identified a good person, but I'm going to vet it out.
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Dr. Ariana
Yeah. And then what is she going to be cross-trained in?
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Dr. McGee
Well, that's the thing. So it's actually a he.
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Dr. Ariana
What's he's going to be cross-trained in?
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Dr. McGee
He's got a cool background. He's an athletic trainer. And then he went to X-ray school.
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Dr. Ariana
Perfect.
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Dr. McGee
But I got to think about-- I think he's the kind of guy that can take the lead on some of this stuff and be in charge of orthobiologics and some outreach stuff. I don't know. I got to think about how I'm going to do it and--
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Dr. Ariana
I think one of the things that we really-- as physicians, don't get too far away from it yet. Don't abdicate your expertise quite yet.
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Dr. McGee
Oh, sure. Yeah.
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Dr. Ariana
Because we're really good at like, oh, you got this? Okay, I got to go do something else.
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Dr. McGee
No, I'm not ready to turn over the keys, but I hear what you're saying.
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Dr. Ariana
Yeah. That's awesome. California is the only state where they don't recognize ATC licenger, so we don't have them and we can't use them in their licensed manner. It's the stupidest thing. Right? So ATC in every other state in the nation is an amazing resource of musculoskeletal education. And what a lot of people use them for are the shockwave applications.
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Dr. McGee
So that was another thing, either that or laser?
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Dr. Ariana
Yeah. If I had to choose and I had a person, I would choose shockwave because I think it makes people better, faster. You're going to get more from more instantaneous results. I don't have the person, so I do laser, and it takes 12 sessions, right? And people get annoyed, and they're like, it's not working yet. And instead, you can get shockwave, and sometimes even one treatment can give you some relief.
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Dr. McGee
So you don't have that in your office?
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Dr. Ariana
I do not have Shockwave.
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Dr. McGee
Is anybody else here using that already? Do you have any strong feelings about a brand or a device or-- I mean, you can send it to me or we can talk about it another time.
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Dr. Ariana
I'll look it up.
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Dr. Matt
Is it the one that Plymouth Medical carries?
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Dr. McGee
Oh, does Plymouth have one?
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Dr. Ariana
Yeah, they do.
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Dr. McGee
I can talk to Joanne. She's been very solid. I mean, you have to--
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Dr. Ariana
Yeah, she's got great recommendations. I think the radio is something that you don't have to run. The focus, I think, is physician-directed. Just be sure that you can make money when you're not there. Right? I would start with one to make sure that you can construct it appropriately and you can identify those patients. It's great with or without PRP, you can add it in your package and bump up your price. I know Pietropaoli uses Shockwave like it's going out of business. And laser, yeah. I think he uses Shockwave. I'm nearly 100%. But for me, people live so far from me that they don't want to come back. They can't just swing in. So you want to make sure that it's effective enough in a smaller number of applications. But then also, I think there is benefit in having them come back and come back and come back because then you're building this relationship and they know the staff. It's like, cheers, hey, hey, everybody. 
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Dr. McGee
Yeah, totally.
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Dr. Ariana
Then they know, like, and trust, and they're like, oh, that's my place. That's where I get better. There is a benefit, but I think, Shockwave-- if I had a person that I could reliably have and know that they were going to be able to do it, I'd choose Shockwave. I think it's probably effective sooner.
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Dr. Sellers
Ariana, excuse me. Where do you implement that with your PRP, protocol-wise? Do you do it before? Do you do it after? Do you do it both?
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Dr. Ariana
Shockwave or laser?
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Dr. Sellers
Shockwave.
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Dr. Ariana
I don't have Shockwave. I want Shockwave, but I don't have a person to run it. I chose laser because it's the MLS laser and you can just set it and forget it, and you don't need any expertise. As long as you have a body in the office to turn it on and put the person under the laser, then I have laser, and I can treat people-- and they have really good, nice results. But I would say Shockwave probably gives you faster results. Oh, yeah. So number one, which laser am I using? It's the MLS M6.
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Dr. McGee
M6. Yeah.
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Dr. Ariana
If you're an orthopedic surgeon, you cannot have an MLS.
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Dr. Sellers
I know.
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Dr. Ariana
Just FYI. But somebody else who you might work with might have one. But then Shockwave, yeah, I can't remember the brand. No, the Stortz, yeah. Stortz.
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Dr. McGee
Oh, Stortz. Who had that? What's his face in Arizona have that?
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Dr. Ariana
Maybe Osh does have laser. I mean, a Shockwave. I think he does. But then what you do is the protocol is-- some people use it before, but it's usually used after. After the platelet-rich plasma injection.
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Dr. McGee
Same day for the first one? Or is that too much stuff?
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Dr. Ariana
I would be speaking out of turn because I don't have it. We'll talk about that.
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Dr. Matt
Do you do laser on the same day?
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Dr. Ariana
I do. I start my first laser that day, and then I have them come back because it's cumulative. I want them to get a good 6-7 in, in the first two weeks. They get 12. If they can come every day for the first two weeks, it's going to be better from a pain control standpoint. So pain, swelling, and inflammation without taking anti-inflammatories, right? I also use it in my surgical because it really accelerates wound healing, which is lovely.
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Dr. Matt
So post-op day one?
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Dr. Ariana
Yeah. So if they can come in at least three days, but if you can do it daily, the research shows that if you do it daily, that it will-- for 2-3 weeks, it will accelerate the wound healing by-- it doubles it. It's pretty impressive. So I think that's something to consider as well. If you're still doing operative or even if you have somebody that's renting space or you're renting space near them, you could be like hey, by the way, you should bring all your postoperative patients. I'm happy to-- did you know that this is a service that we offer? And then just rent that up. There's no-- so Dr. Sigmann, Scott Sigmann is Ortho Laser founder. There's a reason that he has a billion franchises. Now, do I think the franchise is viable for everybody? No, I looked into it and it was not a viable option for me. You have to have a pretty big-- so if you have a five-person orthopedic group, it makes sense to have a franchise, run it through, and have it working five days a week for you. But I will say I paid mine off in a year. Yeah. So now we're free and clear.
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Dr. Matt
We're like 50.
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Dr. Ariana
Yeah. I think it's similar to a Shockwave.
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Dr. Matt
If you're in a building in the same space as pain management, is MLS going to sell to the pain management doc?
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Dr. Ariana
I'm sure.
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Dr. Matt
If they're like, oh, I see there's an orthopedic surgeon's sign on the door. What's up with that?
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Dr. Ariana
Oh, well, so it's not-- yeah, I think it's totally fine. Totally fine. You'll have to see. I got a referral from John Kanab, and I got in contact, and it worked pretty great. Yeah, it's a cutting-edge laser.
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Dr. McGee
Yeah, cutting-edge laser. So Mark is meeting with them this week, and he's going to talk to me after he meets with them. He doesn't know what they want to meet with them about, but he's kicking around. He doesn't know if he needs three. He was like, he might just sell me his third one. He might be too busy. I don't know.
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Dr. Ariana
Yeah. It's working for me. It doesn't require an extra person. It's a pretty small footprint, like a two by three footprint.
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Dr. McGee
Yeah.
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Dr. Ariana
That's not too bad. I think it's a value add for sure.
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Dr. McGee
All right. Tell us about IOF and the latest on PRP because we need to learn that.
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Dr. Ariana
Yeah. A couple of things. The basic science was very interesting. I think that when Peter Everts talked, it was, I think, a really nice talk. I think what I got out of it is that there's going to be a trend coming to be very clear on what your concoction is, not only platelet number, but platelet dose as as well as lymphocyte, monocyte, and granulocyte. I think there's going to be a run on cell counters. If you came away with anything from the meeting, I think it is probably not good enough to not know what you're injecting at this point. Would you guys agree?
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Dr. Diane
Yes.
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Dr. Ariana
Yeah. It was pretty clear. I was like, well, I think probably everybody just needs to know. I think if you got skin in the game and you're doing this at a high level, I think you probably just have to know and calculate and be able to say, this is my dose and this is how I know. I think as we collect data, we're going to find these more nuanced findings, and we'll be able to pull those out. What happens when your platelet count? What happens when you have a low lymphocyte, high lymphocyte, or monocyte? Where are we on this? Because that's what he was alluding to. Then the really fascinating thing that I didn't even think about, but man, it's something else, is that interplay between the immune system and how your immune system is affecting your treatments, and those lymphocytes and those monocytes are affecting our treatments. Do we have to be quite a bit more nuanced and should we be treating stress before we treat a knee? All these things, I was like, oh, my gosh. Hold the phone. Are we going to be whole physicians now? This is strange, but I think it does play into this theme in Mavericks where we are pushing those boundaries a little bit, and we're addressing nutrition, and we're addressing stress, and we're addressing a more holistic approach to the patient because it gets better outcomes. When you have a whole-person approach, you get better outcomes. That was clear in this discussion as well.
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Dr. McGee
Do you think that's pointing to a better understanding of who responds and who doesn't and why? Because you've had this, I'm sure all of you guys have this. Some patients are just responders and get better every time you treat them, no matter what, the injury. Some people struggle, and trying to understand that, how we predict or prep the host prior, right?
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Dr. Ariana
Great question, because that was lecture number two with Jason Dragu. And he was talking about the machine learning, and they have these huge databases that we're amassing samples, not only to look at now, but with assays and all of the small molecules, but then machine learning. And then we can go back when we know more and go, okay, what did that have in it? And then extrapolate out. IL-17 was something that really continued to come up as a marker of people who respond. I think, yeah, it's crazy. Then the next one was the PPP for muscle injury, and PRP did show that there was more fibrosis in muscle rather than the PPP, which caused improvement in healing. That's great. There's also some discussion about low versus high volume PPP for hamstring strains, and there's maybe some indication that low volume is better. That is not a soft problem. I think everyone was pretty clear that there are some interesting findings, and the juries are still out, but there are some arrows and maybe some trends to follow. But this is definitely not a solved problem. But I would say this is the first time where I'm like, oh, my gosh, this is getting really nuanced. And I do think that we are on track. This is actually coming. Did anyone else gather some like, holy cow, mind-blowing pearls? Nothing.
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Dr. Matt
I thought the MFAT with the rotator cuff, the full thickness rotator cuff. I was like, that's pretty badass. Yeah, that was fantastic.
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Dr. Ariana
Yeah. In my talk, I presented some data and some case reports and some case studies with MFAT for partial and full-thickness rotator cuff tears that predictably decreased pain, increased function, out to two years. There is a case study of MFAT causing healing of a full-thickness non-retracted tear at the 10-month MRI. John Ferrell published that, and you can look at that. Just search it. Look at MFAT for Rotator cuff tear, John Ferrell, Ferrell. He's in our group. It's shocking. It's like, no way. I would say it was an outlier, except for the fact that the two case series that I looked at had between 10% and 30% of patients who responded had full-thickness tears.
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Dr. McGee
Is that meeting available on demand?
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Dr. Ariana
I am going to recommend that it be available on demand to members. We have not done that, but at our board meeting, that was the recommendation, so we'll have to see if that'll be on demand or not. I'm not President anymore. Just kidding. I can make some changes. I can make some recommendations. But it was so good.
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Dr. McGee
I think it's the way to capture some more people you know, that can't attend or whatever.
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Dr. Ariana
Of course. Yeah, if you're in Rua town or some weird thing. Moving to the knee, I think the things that were really interesting were meniscus tears, treating meniscus tears with both PRP, which was effective and efficient, as well as MFAT for meniscus tear. It was pretty impressive, to say the least.
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Dr. McGee
Is there a stratification of what types of tears?
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Dr. Ariana
Yeah. So these are all degenerative.
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Dr. McGee
Are you injecting directly into the meniscus?
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Dr. Ariana
Yeah, for both of those movements.
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Dr. McGee
For example, you're placing your probe on the joint line. You're seeing the triangular shape of the meniscus. Is that going to be a short axis then?
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Dr. Ariana
It's going to be out-of-plane. It's going to be an out-of-plane technique. Use your center line and then drop straight down. You'll see that bright white dot, and then you'll see your injectate.
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Dr. McGee
But are you following that around to the posterior horn? Because you know most of our tears are posterior horn?
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Dr. Ariana
Well, it depends. I get an MRI, right, so you know where your tear is, and you can identify it. Then just to be clear, the PRP from Elizabeth Akan, this was a degenerative tear. She was doing mostly peri-meniscal, so meniscocapsular junction.
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Dr. McGee
Capsule, okay.
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Dr. Ariana
Because if you drop all the way into the tear, it slides into the joint, like the injectate. But she thought-- and I talked to her afterward, that it was actually-- she was using a lot in the perimeniscal, like a perimeniscal cyst. Drain it and then put PRP in, and it seems to seal the two leaflets together, so they do not having so much shear and allowing the fluid to leak out. Then Steven Myers used MFAT for symptomatic meniscus tears without arthritis. There was no arthritis. There were just these symptomatic tears. They were horizontally-- these degenerative tears that did not require stitching. Then MFAT. I think those for me, treating meniscus tears-- I did a webinar on meniscus, and I've been treating intrameniscal injections for PRP, BMC, Adipose, and I'm like, gosh, it makes sense. But then I pulled all the literature and I was like, oh, no, this is real. This does make sense. When you treat with PRP, even, you drop the meniscal grade by at least one, if not more than one, when you treat intrameniscal. I'm going to highly recommend it. I think that the other thing that was a recurring theme was to treat that functional unit. So don't just treat interarticular. You treat the whole functional unit, the ligaments, the tendons, the fascia, and interarticular. There was a lot of discussion about interosseous. I don't know that we're there yet, but we're getting there.
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Dr. McGee
If you go like Jack Farr and Vangsness paper is eight years old now where they did a partial menisectomy and injected BMAC and grew back some of the meniscus.
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Dr. Ariana
Yeah, I know. They were flogged. Like that doesn't happen. But I don't know, dude. I think we're getting closer. There's some glimmer of hope. Like, oh, my gosh, there may be-- what we're doing is actually not only changing the natural history of the disease but may also be delaying or even reversing. So of course, the jury is still out. And of course, we can't use cultured cells here in the United States, but there's a lot of discussion about cultured cells as well. We had the speaker last year for IOF showed regeneration and healing with cultured cells for Achilles, full thickness.
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Dr. McGee
Wow. Yeah, it's cool.
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Dr. Ariana
Pretty cool. What else? There was-- oh, who are the-- optimizing the vitality of the patients and providers from Allan Mishra. Did everyone like that talk about vitality? Yeah? Diane, what was your favorite takeaway from the vitality talk?
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Dr. Diane
It's what we do all the time. We spend so much, we give so much, and then we are right at the bottom, our family and take care of the patients and take care of the business. Then here we are.
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Dr. Ariana
Yeah, totally. I don't know if you guys have ever heard this discussion or seen the graphic. It's always so powerful to me. You have to classify your life into rocks, right? So big rocks, medium rocks, and small rocks or sand. So the big rocks are like family, health, your relationships. Medium rocks are like the job, putting money in the bank, getting food on the table, feeding your dog, going for the run, whatever. And then the little rock, the sand, is everything else. So if you put everything else, the little sand in first, and then you put the little rocks in, there's no room for the big rocks, right? It doesn't work. It's too full. If you put the big rocks in first, then you put the medium rocks in, and then you put the sand in, it all fits. But it's all about prioritizing those really big rocks and letting everything else filter in. And I think that's what happens all the time you're like, you do the little crap because it seems easy. You're like, oh, I'm just going to finish up my emails. Oh, I'm just going to let the dog out. Oh, I'm just going to clean the house. But those are the little things. The big things are the things that really matter and are going to be there whether you have a job or not, whether you have the right clothes or the right car. So prioritizing those big rocks allows everything else to fit in between. Yeah, right? Yeah. It's easy to hang on to in your mind. You're like, oh, this is the sand. I can't spend my time on the sand. If you're at the beach, that's okay.
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Dr. McGee
Beaches are big rocks.
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Dr. Ariana
Beaches, yes. For me, skiing is a big rock. I think the other really cool thing that he did was the Million Second Challenge. So a Million Second is about 12 days. And so he asked, and he sent out these little cards, and it said, what are you going to get done in the next million seconds? Three things. And when you look back in 12 days or in one million seconds, you have said, I did this, and I did this, and I did this. It's done. It's already done. So I would urge you to put that on your calendar, maybe every month or so. Just say, in the next million seconds, what am I going to achieve? Not what do I want to but what is actually going to be done? Did anyone have one that they were like, oh, that's good. I like that. Did you guys do that challenge? No? Nothing? Nothing's getting done? Crap.
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Dr. Diane
Not yet. At least for me.
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Dr. Ariana
Yeah. So at the top of my list, I said that in the next 12 days, I'm going to spend time recharging. I've been working pretty hard with not enough rest or sleep or anything. That was my top one thing that in the next 12 days, I was going to recharge. That was really, really important to me. What do you guys do for rest? Tricky, tricky, right?
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Dr. Matt
Would love to hear some ideas.
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Dr. Diane
Go for rest.
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Dr. Ariana
Yeah. Well, we've talked about that. I'm sure you've read the research on ultramarathoners and distance runners, that if they don't prioritize rest, their performance drops. And so they have to prioritize rest to enhance their performance. I think one of the most amazing stories I read about was Mikaela Shiffrin. She's a ski racer, and she sleeps on the mountain until her race, and then she performs and she wins. I'm going to challenge everybody, including myself, to really prioritize and say, this is really important for performance. You have to provide yourself enough time for recharge and rest, a down day. Did you guys do the calendar stuff with Mavericks, with Matt, at the beginning of the year? Where you planned out when you were going to do your deep work, when you were going to do your recharge or rest, go back to that is to actually plan it out. If you're going to be traveling, plan an extra day for rest and recharge. If you know that you have a big stretch of time where it's going to be a push, schedule that extra day for that rest and recharge. That's not catching uptime. That's like downtime, rest, recharge, do what fills your cup, and the work will always be there.
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Dr. Diane
You know, I remember now, and I was-- Deb and I had a fantastic time in Phoenix.
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Dr. Ariana
This was your rest and recharge.
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Dr. Diane
This was one of the most fun conferences.
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Dr. Ariana
Oh, I'm so glad. Well, I have that same feeling. That's why I'm so passionate about IOF. It's great people. It's all the really nerdy stuff, so nerdy. I'm like, Oh, my God, we're talking about molecules. Like, randomized control trials. Yes. But also, that's where I found my tribe, and that's where I found the people who care about taking care of patients. I dream of taking care of patients. That whole patient, whole scheme, not just pigeon holding, oh, I only do right knee surgery, or, oh, I only do the left L4 Foraminal I'm so sorry, that's my expertise. I'm so pigeonholed in that you forget the rest of the patient. And while that's efficient to do that, I think we lose the art of medicine and we lose that connection between the doctor and the patient. When you step outside that insurance model and you get to spend time with these patients where you're like, tell me everything. What hurts? How can I help you? Maybe it's not the knee that hurts, but it's the whole person, and their hormones are off or they need to lose 25 pounds or they need to do a stress reduction program, or whatever. It's just so much more satisfying. That's what I found anyway for myself. Since I've stepped outside of the insurance model, it's so much more rewarding, and my patients get better. They get better results.
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Dr. McGee
So you joined the group where the normal behavior was your desired behavior.
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Dr. Ariana
Yeah. Isn't that crazy? But it's so rewarding. It fills my cup. I love to go to that conference every year, so much so that I became president for two years. Because I was pretty down on orthopedic surgery for a while because for me, it's a really toxic environment, and I felt very, very devalued. I stopped going to all the orthopedic meetings because it was making me feel worse rather than better. And I finally went to this IOF meeting and I was like, whoa, this is different and amazing and so much energy. And it just-- it was great. Do you ladies would agree?
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Dr. Diane
Oh, completely. Right, Deb?
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Dr. Deb
Sorry, my dogs are playing with their toys, so it was squeaking. Sorry about that. That was great.
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Dr. Ariana
Yeah. What was your favorite takeaway from the conference, Deb? Anything that just made your mind go, oh, my goodness.
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Dr. Deb
I just learned some things-- can put some things together, I figure out ways to do like hybridized sections on the patients that cannot afford the orthobiologics where we can actually charge their insurance companies for it and it's not fraud. I'm reading that book about discipline, and it's not that I'm not disciplined, but I think we could all tighten up our routines a little bit more-- anyway, so I bought that book.
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Dr. McGee
What book is it?
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Dr. Deb
It was the one, the gentleman she was talking about, the one that was kind of philosophical. I don't have it in front of me.
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Dr. Ariana
Allan Mishra.
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Dr. Deb
She takes good notes. She takes really good notes. Diane does. She's got it.
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Dr. Diane
Let me see if I can find the name of it.
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Dr. Ariana
Was it Allan Mishra's book?
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Dr. Deb
It was the gentleman that was talking about relaxing and... but he was also--
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Dr. McGee
The vitality stuff.
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Dr. Deb
And, you know, nurturing your body, becoming a patient, you want your patients to be, kind of thing.
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Dr. Ariana
Right. Yeah. So Allan Mishra is an orthopedic surgeon out of Stanford, and he's been doing a lot of work on vitality. He has a podcast called "Vitality Explorers". I'd highly recommend you check it out. I've been really, really enjoying it. And it is all scientifically based. And he reviews three papers every week about how to enhance your vitality. But the best part about the podcast, it's only about 20 minutes. In the end, he gives you three actionable steps to enhance vitality that are easy. You're like, oh, well, I can do that. When you listen to the "Huberman Lab", you're like, oh, that's so good. But you're like, crap, where do I start? Where is Allan Mishra is like, here's three things. Do these three things. And you're like, Oh, doable. Yes, I can do that. So "Vitality Explorers" is really good. I really like it. I've been listening to it for about six months. He teaches a vitality program to undergrads at U of M. He's kicking around, like, how else can we serve physicians in this same way? I loved it. It was great. Let me see. What else? What else did we learn? We talked about some dosing, some PRP dosing, probably between 5 and 10 billion cells for knee osteoarthritis is appropriate for a dose. I would leave that there.
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Dr. McGee
Typical knee injection. Knee osteoarthritis. Describe to me the other-- I think many of us doing orthopedic surgery, we're going to attack the intraarticular aspect and are more than comfortable with that injection and that type of thing. But you just go through, what would a typical comprehensive treatment of that knee look like for you?
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Dr. Ariana
Yeah. I'll describe the typical MRI that everyone is familiar with is Grade 2, 3, (KL)[23] arthritis with a horizontal degenerative medium meniscus tear between the posterior horn and midbody with a little bit of laxity of the MCL. And what else? Oh, maybe some quad tendinopathy with some increased signal and quad tendinopathy. I would address all those. So I would do intraarticular, a usually 10 billion dose that I calculate after I run the Hariba. So depending on my dose or my cell count, I will calculate the number of CCs that I put intraarticular. Then I spend--
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Dr. McGee
How many cc's of blood would you draw for that patient?
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Dr. Ariana
Minimum 120, because I want to spend 10 billion in the joint.
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Dr. McGee
Okay.
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Dr. Ariana
Right. That's going to be at least spending the 60 cc draw intraarticular. You're going to spend the rest of it on the meniscus, on the MCL, on the quad tendon. I think you need more. I think the last time I drew 60, I was treating a thumb. For a thumb comprehensive, it's intraarticular and the ligamentus, so the whole capsule. Then depending-- you know you want to look and make sure they don't have any of this stenosing tenosynovitis that goes along with that thumb arthritis. Because if you do, then I would also treat the--
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Dr. McGee
Tendon sheats?
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Dr. Ariana
With a lower dose. I use ligaments, and tendon dosing is less. Half of the intraarticular, like 5 billion platelet dose.
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Dr. McGee
Got it.
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Dr. Ariana
That's been shown in the rotator cuff literature. All right. Oh, yeah. The other thing is from a literature discussion, the MCID. It's really interesting. There was a whole discussion on MCID, or Meaningful, Clinically Important Difference. What I didn't realize is that the MCID is condition and treatment-dependent. We've been using surgical MCIDs for orthobiologic injections, but that's not the same treatment. Maybe that's not even the same diagnosis. Some of the data companies have been able to calculate and he talked about how you calculate it. You can use either a statistical scatterplot or you can do anchor, which means that you base it on what's important. One of the companies, the DataBiologics company, I know for sure, I don't know about RegenMed, MCID, but they calculate it based on satisfied and extremely satisfied patients only. They look back and say, Are you satisfied? Only those patients, that's the cut-off of the minimal clinically important difference, which is cool, right? Then you know that's the important difference is that they're satisfied. They're satisfied with their outcomes, they're just satisfied with their treatment. What else? We had the FDA regulations. I wasn't in love with that one. Then Sacroiliac appears that there's quite good evidence for treating the Sacroiliac, both intraarticular but also the ligamentus treatment. Again, this is a comprehensive treatment, right? It's the iliolumbar fascia or the ligament, the thoracodorsal fascia, the SI ligaments, kind of pepper the entire thing, and then intraarticular as well. And then--- go ahead.
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Dr. McGee
Can I ask a question?
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Dr. Ariana
Of course.
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Dr. McGee
If we're not doing this already, do you think we could, as a group, like Steel Mill and BFF, I'm a BFF.
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Dr. Ariana
BFF, yes.
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Dr. McGee
Start a Dropbox with the most important and meaningful papers for different topics and share that together. Do we have something going like that?
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Dr. Ariana
It's in the PRP-Now program. It's on the downloadables.
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Dr. McGee
Wonderful.
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Dr. Ariana
Yeah. It's in the downloadables. And if you're an IOF member, it's on your portal. Landmark papers. So yes.
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Dr. McGee
So read is what you're telling me. So read and pay attention.
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Dr. Ariana
Yeah, but that's the funny thing because you don't pay-- it's called conformational bias, right? So if you don't know anything about it, you don't pay attention to it. The second you learn something about it, then it's everywhere. You're like, oh, my God, this happened. Before you were looking, you're like, you finally are doing the research and you were like, oh, red cars perform 10% better. And then you look around and there's like 100 red cars, right?
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Dr. McGee
Yeah.
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Dr. Ariana
It's the same thing. So this happens all the time when I did a presentation for my fellowship, and I only put evidence-based literature that was orthopedically-based, so arthroscopy, AGSM, all of the orthopedic journals, and I was like, these are all in there. And they were like, huh. So you're telling me that was in the journal that I read and I did not read that study? I said, yes, you're correct. Because if you don't know, you're like, yeah, I don't even do that. Whatever. Next. You're like, wrist arthroplasty. Next. I don't do that. Right? And so you don't even know anything about it because you don't know anything about it and you ignored it. It's crazy. And now you're going to be like JBJS, AGSM, Arthroscopy, they're putting all that stuff in there. And so next time you all get your journal, you'll be like, holy crap, it's in here and it's good. And I missed it. But I did put the landmark papers. I haven't updated them in a little bit, but we'll work on that. I think that's a project that I'm working on for IOF as well. So if I'm going to put the work in there, I'll absolutely share with my friends, and my BFFs, what's happening from just the papers that I use, my references. What I can do now is use the references for the meniscus paper in the presentation that I did, which is easy. I'll put that in there. I'll figure out where to put it, and then I'll just post it in the PRP-Now and probably on the main page as well. All right. I don't want to take any more of your time. Any burning questions, any concerns, issues, problems, or things you're wondering about?
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Dr. Diane
I have a quick one.
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Dr. Ariana
Yeah.
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Dr. Diane
I have the new front desk person starting on Wednesday, and I couldn't remember if you have anything in PRP-Now, the documents, and all of that onboarding a new staff member.
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Dr. Ariana
I do. It's more guidelines. It is a step-by-step, but it's not going to be that comprehensive like do this. It is pretty-- then if you're part of BMF, so I think there's an onboarding section on the hiring modules.
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Dr. McGee
The Vinehouse?
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Dr. Diane
Yes.
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Dr. Ariana
I think there is one. I might be talking out of term, but I think there is one on how to onboard. I'm nearly 100% on hiring that there's a resource on that. Look into the resources, but also look at the module on hiring.
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Dr. Diane
Okay. I checked that resource already. There's something, there are some videos, but I'll check yours, too.
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Dr. Ariana
Yeah, I know I have some guidelines, like what to do, how to do, and things not to miss. Then just from my own experience, I think that I would be really diligent about scheduling check-ins, because what we always do is we're like, okay, here's the bathroom, here's the computers, here's the thing. Any questions? Okay, good. You got it? Great. Then you talk to them in three months and they're miserable because you didn't go back and check. I would do at least three times a week check-in minimum for at least the first month, and then schedule every two-week check-ins after that for the first three months. It's going to save you a headache at the end, right, because you don't want to get three months down the road and be like, what do you mean you don't know how to do that? What the hell have you been doing, you know? So I think clear guidelines, clear SOPs, clear communication. And if you don't have your SOPs, I think sitting down and writing them together is probably valuable. Yes, your standard operating procedures. Yeah, SOPs. Because you want to know that they are very clear on what their job is, and what their metrics are. Just like we were talking about at Steel Mill, you want to make sure that you've clearly told them what they're going to be measured on before you measure them. And then make sure you're measuring it. So make sure there's an objective way and be like, yes, so you're supposed to do 30 calls a month, and here are the calls you've done. You've only done 10. We're deficient. How can I help you? Where's the disconnect? What's standing in your way of meeting that metric? And it might surprise you. You're like, oh, well, your phone system is broken. You'll be like, oh, well, that's an us problem. That's not a you problem. Great. Thank you so much for bringing that to my attention. But that clear communication, right? You're like, oh, I thought so and so told you. Oh, you didn't know the phone's broken? And you're thinking, the phone's been broken for a week and nobody said anything? Sweet.
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Dr. Diane
What metrics? Just for your new patient person, I forget what the title that the person has. Just briefly, because I know we're short on time, what metrics do you have for that person?
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Dr. Ariana
My metrics, I'd have to look because guess what? I don't calculate them. We review them every week. I review metrics, and my office manager monitors them, calculates them, and then we all talk every Tuesday. It's Team Talk Tuesday. At lunch, we sit down, I buy lunch, and we talk about our metrics and our goals and any things that are standing in the way. That's been super helpful for us to not lose sight of what we're doing. You could even buy tacos for Team Talk Tuesday tacos. But I think that that's been very, very helpful for my office because now we all are on the same page, what our goals are. So what our quarterly goal is, what our tasks are, how we're going to get there, and then what each person's task is every week, what their metrics are, and how it's going. Is there anything that's really-- they're struggling with and that we need to address? Good?
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Dr. Diane
Thank you. Absolutely.
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Dr. Ariana
Awesome. But yeah, my front desk person is like new patient calls, % conversion, or % scheduling or something. We measure both of those. And then she's also in charge of the nutrition. So then she has to make sure that she reaches out to 75% of our clients every week.
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Dr. Diane
Oh, wow.
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Dr. Ariana
Those are her metrics. And she made those. I asked her, I said, what do you think the three most important things are to say, I'm doing a good job at my job? She's like, well, I think this-- what do you think a good measurement would be? 50%, 100%, 80%, and then you can always come up with bonuses or something like that as well.
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Dr. Diane
Great. That's helpful. Thanks.
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Dr. Ariana
Yeah, sure. Anything else, Deb? Do you have your hood yet?
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Dr. Deb
Oh, yeah. They're coming to certify it I think, on the 16th. I'm having my back done at Centennial Sheltz this Friday, so we can't do anything until-- oh, we're waiting for the anesthesia license for that second location. That's the other thing. Other than that, I'm hoping we'll be ready to go by the third week in February.
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Dr. Ariana
I'll keep my fingers crossed for you.
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Dr. Deb
Yes.
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Dr. Ariana
So annoying, right? All the little hoops.
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Dr. Deb
I know, I know, I know. But it'll be good once we get started.
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Dr. Ariana
Well, Cool. I will share something with you that I learned yesterday when we did Matt's back. So Osh has sedation for all of his back injections at his clinic, and I do not use sedation for all of my back injections at my clinic. And I figured out the difference is that I use anesthetic in my injections, and he does not.
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Dr. Deb
I got you. Yeah, I got you.
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Dr. Ariana
So if you are choosing to do injections without sedation, I'm going to highly recommend dilute anesthetic. There's really good evidence that dilute anesthetic, like Ropivacaine, like a 0.125% Ropivacaine, does not change the way that the PRP works or the platelet lysate works. It just makes it more comfortable.
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Dr. Deb
Well, these are old patients of mine that, trust me, and they're used to actually having a CRNE in the room. We are going to go with doctor-directed RN sedation, but there's just no way these people would tolerate not having-- they wouldn't even sign up if they didn't think they-- were having sedation. But maybe some of the newer patients, I'll try that comprehensive lumbar procedure with 0.125 but just have some Versed and Fentanyl handy just in case.
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Dr. Ariana
Yeah, I will tell you the number of Versed and Fentanyl cases I've done, zero.
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Dr. Deb
I know.
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Dr. Ariana
But this is your practice, and that's what-- Osh and I were joking. It's like, I never sedate. And he's like, I always sedate, but he doesn't put anesthetic in. So he uses sedation. If you're not going to do sedation, then I would highly recommend anesthetic because-- I mean, that was not that comfy. And I was like, oh, my goodness. And then it dawned on me like, hello.
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Dr. Deb
There's a commercial side to that. I had to say it. It's not that big anymore. But we used to hire CRNAs for X dollars an hour, and then we would bill being anesthesia background, it's just fine fellowship, but anesthesia background. I got to charge for the anesthesia. I got paid more with the insurance industry with the anesthesia than I did for my procedure. So that's kind of where that was born.
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Dr. Ariana
Of course. But I don't know that you can do that if you're doing--
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Dr. Deb
Well, yes, you can. My periodontist friend charges $600 every time she sedates the patient for a procedure. But I agree with you. It's so much better if you don't have to sedate. It's better for the patient. It's better for the recovery. If you can avoid it you should. If you can.
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Dr. Ariana
I'm just giving you guys an experience that there's more than one way to do it. But if you're going to go with no sedation, I would recommend some local because I was like, whoa, this is uncomfortable. Okay.
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Dr. Deb
Are you having to give a lot? Are you totaling your-- I mean, what are you doing for your local? I mean, we all put local in, even with this sedated patient, but what's your total of 0.125 for facets, multifidus, epidural, and ligaments? What's your total of your local-- of your 0.125 Ropivacaine, got to be?
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Dr. Ariana
Well, if you do the math, it's probably about 3 cc's of 0.5 Ropivacain.
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Dr. Deb
Okay.
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Dr. Ariana
Total.
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Dr. Deb
Okay.
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Dr. Ariana
It's like nothing, right?
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Dr. Diane
For all those injections, you just use 3 cc?
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Dr. Deb
Well, multiply it times her dilutent to get it down to 0.125.
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Dr. Ariana
Yeah, but what's your dilutant, right? It's PRP. So 4 cc's of PRP with 1 cc of Ropivacaine is then 0.125, right? Yeah.
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Dr. Deb
Oh, I see what you're saying. Oh, I was thinking you were preanesthesizing with 0.125.
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Dr. Ariana
No.
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Dr. Deb
Okay.
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Dr. Ariana
I use lidocaine for the skin.
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Dr. McGee
All in together?
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Dr. Ariana
Yeah. I put it in the PRP, dilute it down.
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Dr. McGee
How much can you get in a facet? How much total volume? One?
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Dr. Ariana
Yeah, 0.5 to one. If you do one in an arthritic facet, it's going to be pretty grumpy.
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Dr. McGee
Pretty spicy.
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Dr. Ariana
Well, except for the Ropivacaine, it's not.
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Dr. McGee
Yeah.
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Dr. Ariana
Not until like later.
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Dr. Matt
Do you have any post-care if their pain gets worse, or if it flares? Any meds that you prescribe, or what do you recommend or what variables?
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Dr. Ariana
My post-procedure medications usually vary between Tylenol and Four Shoulder, Intratendinous, I give a Norco. Just 48 hours worth, though. I usually give them eight pills.
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Dr. Matt
Okay.
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Dr. Ariana
Yeah. I'm pretty stingy. Plus my pharmacy is really crazy. Our town is on the FDA watch list.
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Dr. Matt
Fun.
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Dr. Ariana
Seriously. Seriously, it's crazy. It's mind-boggling. If you are established at a pharmacy, you cannot go to a different pharmacy for any reason. It's nuts. And they're out. They're being restricted significantly on the number. So by the end of the month, none of the pharmacies have any narcotics.
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Dr. Deb
You're in the People's Republic of California, though, right? Sorry. I'm just kidding.
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Dr. Ariana
But I'm in [inaudible] -- right. No kidding. But seriously, we're in the top three counties in California for narcotic use per capita.
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Dr. Deb
Wow.
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Dr. Ariana
Maybe top one. I think we're number one. Yeah, it's not good. It's not good at all. That means everybody's abusing it, unfortunately. There's enough for every man, woman, and children. All right. Any other burning questions?
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Dr. Matt
Can you connect me with your MFAT rep, the joint?
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Dr. Ariana
Joint Tech Labs?
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Dr. Matt
Yeah. Them.
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Dr. Ariana
Yeah. Matt. Yeah, they're great.
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Dr. Matt
Perfect. I'll send you my email.
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Dr. Ariana
That sounds amazing. Yeah, just message me on my cell and we'll call it good.
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Dr. Matt
Perfect.
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Dr. Ariana
Awesome. All right, guys. Great to see you. We'll see you next week.
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Dr. Deb
Bye, Diane.
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Dr. Diane
I'll call you.
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Dr. McGee
Have a good night.
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Dr. Matt
Bye, guys.
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Outro
This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more, please join us on the website "PRP-Now.com", and click on the FREE Masterclass. Also, don't forget to SUBSCRIBE to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.
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