Amy Loden Tiffany, MD on Metabolic Health, Habit Change & Building Personalized Medicine

[00:00:00] And the more I thought about this message, I realized it's not universal to women, it's actually universal to each of us because of how pregnancy impacts everyone. I kind of joke in the TED Talk, has anyone figured out how to get here outside of a pregnancy, right? And all of us come from pregnancy. So if we have this novel part of all of our lives, how are we not using that to impact our lives after pregnancy?

[00:00:23] So the obvious person affected is the mother and the pregnancy impacts on her. We're starting over the last decade to really hear more about the research that's coming out on that past Eve. The less obvious is what is it doing to the child and at child's health down the road? And there's two implications of that. One is if the child lives with other...

[00:00:43] Hi, and welcome to The Holistic Entrepreneur, where we explore innovative approaches to healthcare through conversations with pioneering practitioners. I'm your host, Zane Myers. Let's dive into today's episode.

[00:00:58] Welcome to this episode of The Holistic Entrepreneur, where we interview interesting people in healthcare. And I have Dr. Amy Loden with me. I'm going to just jump into the TED Talk because tell me the origins of that and how you... You must have given that talk before you did the TED Talk because you're usually done a thousand times before. So tell me how you got to that talk.

[00:01:25] And let's just talk about the story because I think the story in and of itself is just really interesting. Sure. So for me, the TED Talk was about getting a message out to women who would otherwise not know it. And the more I thought about this message, I realized it's not universal to women. It's actually universal to each of us because of how pregnancy impacts everyone.

[00:01:46] I kind of joke in the TED Talk. Has anyone figured out how to get here outside of a pregnancy, right? And all of us come from pregnancy. So if we have this novel part of all of our lives, how are we not using that to impact our lives after pregnancy? So the obvious person affected is the mother and the pregnancy impacts on her. We're starting over the last decade to really hear more about the research that's coming out on that capacity.

[00:02:11] The less obvious is what is it doing to the child and that child's health down the road. And there's two implications of that. One is if the child lives with the mother, presumably how the mother eats, prepares food is what the child will learn to do. But two is something called epigenetics, where the environment around the child. So the intrauterine pregnancy and environment directly impacts how the genes of that child form.

[00:02:36] So a mother who has gestational diabetes, not only is she more likely to have diabetes, five years later, half of those moms have type 2 diabetes. Oh, I didn't know that. Yeah. But her child has an adult onset diabetes risk much higher than the general population. And both of those can be mitigated risks. Similarly, preeclampsia, a mother who has preeclampsia has a much higher chance of dying before the age of 60 from heart disease.

[00:03:04] But her child from that pregnancy has a much higher risk of having high blood pressure and heart disease as an adult. So this is much bigger than just the pregnancy. And unfortunately, in her medical system, the pregnancy is the focus, not what we do with mom long-term health or the child's long-term health. So how do you mitigate those? A lot of preventative strategies and a lot of it has to be recognition that it's even a risk.

[00:03:29] So right now in the system, if you will, the American health care system, this is not a risk that moms are talked to about. And if you look at the OB literature, they'll talk about how not even a third of moms get their postpartum gestational diabetes screening that's recommended. It's not for lack of recommendations. It's lack of follow-up. And if you think about it, why are these moms not going to the follow-up appointments? Because they feel okay and they've got an 8- or 12-week-old baby that they're just trying to figure out how to be a mom.

[00:03:56] And so they don't feel like they need to go to the OB appointment and the screening never happens. Because certainly it isn't well understood within the primary care providing population either. It might be tested here and there on a board exam, but it's not something that's in their practice every day. So if the healthcare, if the healers aren't educating because they themselves don't realize it's such a risk, and they're not telling the patients, the patients certainly don't know it unless they go on their own deep dive.

[00:04:23] And so you've got this whole group of people on both sides who doesn't know it's a problem. And that is a problem. So the first thing we have to do is educate people. The second thing we have to do is teach them how to change the fundamental habits that got them where they were. Because everything you are today is a production of the habits that brought you to this moment. If you want to be different in a year, you have to change something you're doing, some habits, some beliefs, and so forth. So how do you change habits?

[00:04:50] That's a whole big issue in and of itself. One of my favorite books I imagine you've heard of, your listeners have, is Atomic Habits. James Clear wrote that book, very fascinating book. And he makes the argument that I think is right, that this is not about doing something every day for 21 days or for six months or whatever it is. It's doing it repeatedly and quickly to make new brain formations.

[00:05:17] The more you do something, the more quickly you do it in repetition from the last time you did it, the more you're likely to integrate that into your own system of habits. Now, I'll tell you what I've learned in my practice. And what I think is true that many people will be able to use practically is to stack habits. So for me, one example, you tell me to go for a walk on my treadmill and it's like pulling teeth to walk downstairs to get on the treadmill and actually do it, right?

[00:05:46] In my house and I can't get it done. But I have figured out that if I time it so that I have to do something else I do want to do. So maybe it's I'm reading this book and I want to read on my Kindle. I will put my Kindle up on my treadmill and read while I walk. So coupling a habit that I already know I need to do with something I really enjoy doing at the same time has been tremendously helpful. That's a good one. It makes a difference. The other thing is you lower the barriers to resistance.

[00:06:15] So still with that treadmill example, I live in a colonial style house. We have three floors. Treadmills were in the basement. My bedroom's on the top floor. Whether I'm first thing in the morning or after the kids are in bed at night, you can't pay me enough to go upstairs and get my tennis shoes to then go downstairs and get on my treadmill. Like I'm happy sitting at the kitchen counter, right? So I leave my tennis shoes on my treadmill. They are stationed at the treadmill to reduce the resistance so that all I have to do is walk downstairs.

[00:06:42] Anything like that, repetition and then reducing barriers to action are what I have found to be most helpful. So tell me about the talk itself because now I remember watching it and it touched me emotionally. But I don't remember exactly what the talk was about. So it refreshed my memory again. I just remember that I thought, wow, that's really a great talk.

[00:07:13] So I wanted people to realize not just the long-term implications of pregnancy, but I also in some ways needed to just absorb and understand my story and the trauma that I had gone through that I was finally ready to deal with. Because I know from different women I've talked to, they've had similar stories. My first pregnancy, second pregnancy were what they were, but my third pregnancy literally nearly killed me. I developed heart failure. It was an emergency C-section. I had twins.

[00:07:41] And I remember lying on my back, being wheeled into the operating room. You see the hospital lights flashing overhead, just like in the movies. And I remember thinking, I'm going to die or one of my kids is going to die tonight. It just had this horrible foreboding sense. I couldn't breathe. My heart was failing. And I knew that we were going into this operation with a real risk. I knew the babies would be going to the NICU. With a medical background, I knew that this was a real concern. And I just remember thinking, this is really bad.

[00:08:11] And for the next 11 weeks, as they were in the NICU and we were recovering from that experience, I pushed that trauma aside. I went back to work two weeks postpartum because I couldn't deal emotionally and mentally with the trauma I had at that time. Trauma, things like, I'm a failure. I'm a bad mom. I caused this. Your mind does things to itself when you go through an experience like that. So for me, the talk was about not just getting the message out, but healing. Healing and saying, why did this happen?

[00:08:40] And where do we go from here? And a lot of it for me was saying, as a Christian, how do I use this in a way that's meaningful to other people? How can I help in a better way? Rather than just, yep, that happened to me, check a box and move on. I think a lot of us, myself included, want to check that box rather than dealing with the hard stuff. And then in dealing with it, I really began to see this is a gap in how care is provided to other mothers.

[00:09:09] I survived that night and I survived a lot of the follow-up of all the pregnancy complications from each pregnancy because I am a physician and understood what the risks were. But when I went and talked to my fellow physicians, like I was saying earlier, they just don't understand that risk at the level of data exists. Five years after having a pregnancy of gestational diabetes, half of those moms are going to have type 2 diabetes, right? That's a lot of moms when you consider that 15% of pregnancies are five.

[00:09:39] Repeat that one more time again. Yeah, so it's 50% of moms who have gestational diabetes within five years will develop type 2 diabetes. That's global. And then when you think that 15% of pregnancies are impacted by gestational diabetes every year, that's a lot of moms. Yeah. So can I get you to hold, there's some other noise going on in my house. So I have my studio in the house and I need to go deal with that. Go do it.

[00:10:09] But like three minutes, probably right back. So I apologize for that. But I also have married and my wife was outside watering and I'm in the basement. My office is in the basement. And for whatever reason, when she turned on that water, it was like some sort of earthquake or something was going on. It's like, oh no. Not this time. Yes, yes. So I went upstairs and said, oh sorry, your plants are just going to have to dry out for a little while.

[00:10:38] And then she gave me this look like. Okay. Wasn't supportive, but I wouldn't say it was. It wasn't necessarily malignant either. All good. No worries. So you're just saying 50% of mothers with gestational diabetes end up with diabetes within what period of time? Within five years. Within five years.

[00:11:05] Does that have something to do with the weight gain that so often happens following pregnancy? Are those two related? It could be. But we have a lot of women. So in myself, I'll give you an example. My first pregnancy, I was a total normal weight. Got pregnant. Had gestational diabetes. Had the baby. Went back and said, what should I do to prevent type 2 diabetes? And both my OB and my primary care doctor said, your weight's normal. You don't need to do anything. Just don't eat too much. And that was only 12 years ago.

[00:11:35] So we have a long way to go because those are the same responses women today still get from most of their doctors and nurses. So what do you do? Yeah. So what I think of it as, and kind of the premise I hoped to have put in the talk that I wanted people to understand, is that pregnancy is not causing these problems. Whether it's gestational diabetes, weight gain, preeclampsia, whatever. It's unmasking them. They're already there.

[00:12:01] And they're present in people who aren't necessarily stereotypical risks. There is absolutely risk of people who are overweight, but there's equally risks of people who aren't overweight. And so stopping the judgment we have based on someone's waistline and starting to look at it from what is their metabolic cellular health is much more important. You may have heard the term skinny fat. That's something. Oh, yeah. Yeah.

[00:12:29] A lot of noise is happening around that concept. But what it's really saying is that you're metabolically overweight. And so in our practice, we spend a lot of time teaching people is how do you eat metabolically well for your body? Because most of us have some degree of metabolic illness that's not being picked up by most traditional tests or certainly not being talked about at annual wellness businesses.

[00:12:55] So what would be, so this brings out like a hundred different questions. So what kind of tests would you do to establish someone's metabolic health and where their deficiencies would be? Yeah. So there's lots of ways you can do it. The way I tend to approach it today will not necessarily be what I'm doing in five years, right? Because we should be learning and growing and evolving. And I certainly have from what I was doing five years ago.

[00:13:23] But what I can tell you today is we're looking at things like insulin resistance. We're looking for markers of systemic inflammation from the liver. We're looking for evidence that the cholesterol types that your body makes are those that are harmful to you. And we're doing tests that may not be covered by insurance all the time. So health insurance sets a rule of what they'll pay for based on what certain government agencies recommend.

[00:13:48] But there's those agencies, everything they recommend lags what's available in the clinical world because it has to first be studied for X number of years often before it becomes accepted. And then from their insurance pays for it, people get it. And so it's really a frustrating process because if you don't have discretionary income that you can spend on some of these tests, you're never going to know that you could do them, number one, because no one tells you. Second of all, you may not be able to pay for it, right?

[00:14:17] And so there's a very practical thing here that is an obstacle that we have to overcome as a society. But those tests make a big difference. So, for example, the lipoprotein, the A subscript A, we have, we've been measuring that practice for several years. Only last fall did a massive study come out in the New England Journal of Medicine that said it was one of three markers that all women should have tested because it predicts the early risk of heart disease and stroke.

[00:14:43] It's going to take a while for that research to be implemented and for all the big agencies to start doing it universally. So, it's a little bit tricky if you want to lean into the science and say you're an evidence-based practitioner and yet the science is ahead of clinical research. Right. And that's something that we all have to figure out how we're willing to deal with it. Each person's license plays into this too because you don't want to lose your license doing something that's not acceptable.

[00:15:11] So, we have to be very careful and cautious so we do it in a way that's health promoting without being scammy. And sometimes things feel scammy because clinical science hasn't caught up. So, how do you do like in this case where you have a study that supports, you know, a particular practice but that's not enough to move the insurance companies and maybe something might be off-label versus, you know, contraindicated. Those are totally two different kinds of things.

[00:15:39] So, what's your take on doing things that are off-label so to speak? Yeah. Off-label for me is a lot less scary than contraindicated. Yeah. Yeah. Yeah, obviously. But contraindicated too could be totally wrong. Correct. I can't necessarily think of something I've done that's contraindicated because I feel like that's probably too scary. I would have braided myself with that in my brain if I knew I did that.

[00:16:05] But I do think I do things off-label as does every other physician and nurse. There are times we use medicines off-label. I'll give you an example. Propranolol sometimes we use to help people with speaking anxiety so that their heart doesn't feel like it's bursting out of their chest and they can slow down and focus, right? Xanax we might use for panic attacks on airplanes. So, people use things off-label all the time.

[00:16:27] It gets a lot more noisy and confusing when we're dealing with not just off-label but compounded medications. So, within my world of obesity medicine and hormonal health, I run into this quite a bit in both trajectories where you'll have compounded hormones or you'll have compounded semat with tight salts. And they're cheaper and people want them and they feel like they're better. But that's a lot more scary to me is compounding than just using something off-label.

[00:16:57] I think for the most part, most things that are used off-label, you can find something to support that. And it's more when we're starting to get to the real murky waters that people start getting a little bit of an ulcer. For me, I won't prescribe semaglutide salts. They have the word semaglutide in them, but I'm not willing to put somebody's health at risk taking something that isn't actually regulated or studied in any way. It is. So, what do people use that for when they are using that?

[00:17:26] Weight loss. They're using weight loss. Like at med spa clinics, for example, there's others too. But, and they'll tell you that it is. That's like this semi-glutide kind of. Yes. Yes. There's just a lot of questions that come up and everyone who uses them or who creates them is going to have their justified reasons for doing so, right? So, I'll leave that to you to discuss with them. But when I've looked at the science, I just can't get behind it. It doesn't seem like it's truly in the patient's best interest.

[00:17:57] And, you know, as a healing professional, that's something we took a vow to do is to do things in our patient's best interest. Mm-hmm. So, it's hard because, again, not everybody can afford even the compound of these. It's not fair. It's not equally distributed. If you have Medicare, good luck getting these, right? You're paying out of pocket for them. Same thing with Medicaid. And many plans exclude weight loss drugs. Right. So, then you have to say, well, am I going to use something off-label?

[00:18:23] Am I going to use pills or injections that are approved for one reason in a different way? And certainly, we did that with pills for a long time. And it wasn't until these injections, which are quite expensive, became available that did anyone start complaining about the off-label use of them. But this has been going on for a long time. This is not new.

[00:18:43] Yeah, that's because, well, that whole classification of drug is now becoming, you know, the biggest seller on the planet because people can. And so, I'm sure, like I know people, and I'm sure that you do, that have been chronically overweight and less than healthy for all of their life. And then suddenly, they get on some sort of semi-glutide type drug.

[00:19:09] And now there's multiple different ones that are in addition to the ones that are compounded. And it's really changed their whole body. And I know that there's certain negative parts of them, you know, you have to exercise. And there's some things about them that are negative. But overall, when I see someone go from 270 to 180, and 180 is really where they belong.

[00:19:38] And he's been at that 250 to 270 for as long as I've known him. It's really something to see. Yeah, absolutely. There's no doubt they have profound impact. No question. My concern with them a little bit, maybe a lot, is that I don't think most people taking them realize they're not going to be able to come off of them.

[00:20:05] And that if they do try to come off of them without having significant change in what, how, and how much they eat, it's going to come back. And so, I think it's unfair to tell people, go on this medicine and then wait and see. I think you have to get to that underlying root problem, whatever was causing it. And almost inevitably, there's a degree of insulin resistance. It is really rare that I find somebody who's putting on weight, can't get it off, and they don't have insulin resistance.

[00:20:35] But see, that's not a standard test that we brought. That is something that we really figure out by looking and thinking deeply about the labs. And I'll give you the hemoglobin A1C test as an example. A normal A1C is considered 5.6% or lower. But if you take that 5.6%, you say, well, what's the average glucose associated with it? It's not a normal glucose. A normal glucose is an A1C of 5%.

[00:21:01] So, we're telling people who are living with A1Cs between 5 and 5.6%, you're normal, when in fact, they have insulin resistance. And that insulin resistance will catch up at some point. It'll either show up in the form of prediabetes and diabetes or weight, ability to not lose weight. And the third thing we're seeing is starting to become more apparent is insulin resistance probably contributes to high blood pressure and is tied into cholesterol and fatty liver disease.

[00:21:28] So, this one factor that no one's talking about is a common denominator in multiple processes that if we let them all play out to their worst extremes, ends up with heart disease, diabetes, dementia, kidney failure. That's crazy. Why are we not being more aggressive earlier? So, what would you do? So, what we do do in our practice is we check that lab and then we start teaching people what insulin resistance is.

[00:21:54] We have people wear continuous glucose monitors for 30 days, changing nothing in their diet. And we say, okay, what did we learn from this? And a lot of times the patients will come in and say, oh my gosh, I didn't realize this was going to cause my glucose. It was a good food. It was a healthy food. And I learned that myself eating quinoa. Quinoa, most people think is a pretty good food, right? Well, if I eat a half a cup of quinoa, my blood glucose, my blood sugar goes over 200. If I eat a quarter of a cup, it stays where it needs to be.

[00:22:22] So, something even as simple as understanding that normal, healthy, whole foods could cause the sabotage of the same problems as unhealthy is vitally important. And that's just not something that we're taught. So, when you said when I eat quinoa, so when you eat quinoa, then you may have one result. When I eat quinoa, I may have something completely different. You got it. Exactly so. Same thing with fruits.

[00:22:50] You might be able to eat two servings of fruit, whereas I can only eat one. Or maybe you can eat two and your buddy can eat three. So, each person's body responds differently. And one of the beauties of population health is we can tell you what the average person's goal should be. But that does nothing for the personalization of medicine. And that's really what we focus on in practice. How do we personalize what we know about population health and data to you as an individual? Because you could be doing everything right.

[00:23:19] And so many people come in and they swear up and down, I'm doing exactly what I should do. But great. I believe you. But let's figure out where it's sabotaging you because something's not working. So, let's talk about your practice. Okay. And what you guys do that's different. Yeah. So, we opened the practice in June of 21. So, we're finishing our fourth year almost ready to ring that five-year bell mark. Looking forward to that. That's a big deal. It is. It is. I told the staff, I think we'll go out to lunch that day because it's pretty exciting.

[00:23:49] But what we started as is not nearly where we've ended up. We started as a concierge's primary care clinic. And the intent was just to do really phenomenal primary care. We give longer appointments. We have fewer patients to facilitate that option. We give people their urgent care here as much as we can. So, if you're sick, you don't have to go to urgent care. We'll give you the IV fluids. Take care of the wounds. You know, all the basics. But what we've learned is that that's not enough.

[00:24:16] Really good primary care should actually also include longevity care. And the model in the American healthcare system is do an annual wellness visit. Check your cholesterol. Make sure you don't have diabetes yet. Your blood pressure is okay. And then we'll see you in a year. That does nothing for a decade from now health. And in our practice, we're focused on what is not just your one-year outcome, but what's your 10, 30-year outcomes. Because I don't know about you. When I'm 80, I want to be able to hike across Europe if I want to do that. Right?

[00:24:45] I don't want to be stuck in a wheelchair in a nursing home. But that doesn't happen when you're 79. You don't make that decision. You have to be aggressively interventional decades ahead of time. So for us, we see people a minimum of four times a year. We have them do labs every quarter. We look at those labs every quarter. Once a year, we actually prepare them an annual longevity report personalized to them. And we're working hard with these individuals to say, here's your health threats. Here's your opportunities.

[00:25:15] What is realistic in your life right now? And we make the assumption that every person is an expert in their own life. So rather than me saying, I want you to work on your blood pressure, I want them to tell me, I'm concerned about this aspect of my health. And this is where I want to go with it. Doesn't mean we don't tell them that blood pressure is high. Right? Doesn't mean that we don't offer solutions for that. But we have to understand what do they want. And as a business owner, I find it very important to understand what is a person, each person, what are they looking for?

[00:25:44] What are they going to find value from? Value is not defined by you or me. It's defined by our client. And so understanding what does my client find valuable and then giving that to them and then adding in all the extra is just a bonus to them. And so that's how we've really evolved to the space where we are today. We do quite a bit with perimenopausal and postpartum women. We do quite a bit with weight loss medicine. And we focus on the long game, not what's next year.

[00:26:13] So how would you, so let's say I come into your practice and I am typically, you know, I've been on this insurance. I have my regular primary care, but I'm really not totally satisfied. This may be describing your ideal patient. And then, and then I come to you because I think I heard something about you guys that you do things a little bit differently. And I want somebody to give me a little bit more attention.

[00:26:42] How would that, how would the first visit go? What would you, what would you tell me as a patient? Yeah. So actually what I would do a lot of listening, a lot less telling and a lot more of just saying, where are you at today? And where do you want to be in a year? What's different about your perfect health vision in a year that you don't have today? One thing that's different about our first visits is there, we allocate them for an hour, even if everyone doesn't want the whole time to get an hour. And I block both my schedule and my nurse practitioner schedule.

[00:27:10] So we're both there focused on you for the whole hour. And we're, we ask the other question, what do you want to be different? And you're going to tell us, you might say, I want to be stronger. I want to keep being active at the gym. I want to decrease dairy in my diet, whatever your thing is. And of course I'm making all this up, but we would ask them to tell us. And then we would talk about what are the barriers to getting there? What hasn't worked for you so far? What have you already tried?

[00:27:36] We're going to ask them if they've had any recent labs the last three months, say, and they, a lot of times they're on their cell device. And so they can pull those up and we'll look at them. Sometimes we'll have to request them separately, but we're going to look at whatever recent labs they've had. And generally we're going to order more labs. We're going to order updated labs. It's very practical that people are used to getting their blood count, their thyroid, maybe their liver and kidneys. They're not really used to looking for all the other things.

[00:28:00] And so they're not used to understanding what the lipoprotein particles mean, what the GGT from the biliary system, what it's showing us, what the high sensitivity CRP is. These different markers that tell me, hey, this person is clean and shiny on the inside, just like on the outside. Or we've got some problems on the inside we need to focus on. And once I understand what's going on with them, I sit back down with them and say, OK, here's what the data shows us. These are the things I think are concerning.

[00:28:30] What do you think? What do you want to work on? When you talk to me the first time, these are the things you said. This is how I see the data is showing us. These are some options for going forward. What makes sense to you? And most of the time, I only let them choose one thing to work on. Sometimes if they can really convince me, then they can do two. But I think changing more than one thing at one time is really tough. So we work on it for 90 days, a quarter. And they can either do it independently or they can use our health coaches.

[00:28:57] But I have them really focused down on what is that one thing we want to change? Let's get that to be a habit in our life. We'll repeat the labs 90 days and we see where we need to go. Sometimes we're done. We just go to the next habit we need to change. Sometimes we need to dial back and change more of this habit. But sometimes we find that one of those things we thought was going to be a good idea, sabotage them and we have to reverse. So there can be a lot of ups and downs. And I try to warn people, this is an experiment.

[00:29:25] Your body is going to tell us what's the right thing for it. And we're going to listen to your body and move forward based on those results. So if I'm coming to you, then it's during the... Is it always 90 days in between when we're working on this? So no. The short answer is no. I would say the majority of the time it is because it's in most people's lives. It's not practical to make changes faster than 90 days. It's just a stake.

[00:29:51] We do have a accelerated change membership that we only allow very few people to be in. It does cost more. It is more intensive. And those individuals are doing labs every 30 days. But it is rare, myself included, to make sustainable change in 30 days. Now, you get results faster if you do it in 30 days. But you really have to be in the right place in your life and have the right support to be able to do that.

[00:30:18] So it's very rare that I push someone to do more. Most of the individuals are those who've already identified for themselves that 90 days is too slow. They want faster results. Okay. Try this. But you can go back to the 90 day at any point. So one of the things that – so I'm one of those types of people that let's just do it. And I want to get in there and, you know, change everything like my diet and how often I exercise.

[00:30:47] And, you know, I just kind of the way I'm – it's either on or off. Yes. And my wife, she doesn't go for that. She doesn't – she wants to eat a completely different way than I want to eat. She does completely different exercise things than I do. And how do you – when your spouse is, you know, maybe supportive of you but maybe not.

[00:31:15] Like I did really well on a keto diet and I was on a mostly keto type diet for, I don't know, a number of years. And I lost like 30 pounds and I was – and I've pretty much kept it off. But I've gotten off the keto diet. I've got so tired she was – she was not happy with that. She said, I can't do a keto diet. It makes me sick. But how do you do that when you have a spouse who's one way that metabolically we're just totally two different people?

[00:31:45] Well, the truth is most people are metabolically two different people, right? It's very rare that a husband and wife or husband and partner can do any of the same things. It just – our bodies are different. So my advice usually is let them eat the way they're going to eat. Just let them – this is not a two-year-old who depends on you for sustenance. I would hope that your spouse can feed themselves. So let them. It's okay. Nothing's gone wrong. They have agency. That's it.

[00:32:14] So we usually do better. Now I'm drifting off topic. But like I said, I get curious. And we usually do better when we just – we're not cooking for each other. We're just kind of totally separate. Get whatever you're going to get. I'm going to get whatever I'm going to get. And then if we go out or something, then you order your own thing. The value I think that families, even without kids, right? A couple of family. I think that the value those people get is not in what they eat together.

[00:32:43] It's in the time they spend together while eating. So whether you're out to eat or in your kitchen, get what you want to eat. And then sit down and eat and enjoy being with each other. Because that's what eating together as a family is about, in my opinion. It's not about actually criticizing the other person's food or changing your food to match their preferences. It's about being together. So how many practitioners are in your practice? So full-time nurse, myself and my nurse practitioner. And then I have a part-time nurse practitioner as well.

[00:33:13] Okay. So is this something that you are – you're at the place where you want to be and you don't want to be any bigger? Or you'd like to grow it? Or you just want to – No, no, no. I do intend to grow it. I have four kids. My oldest is 12. So there's a little bit – I have four kids too. Any. Although my oldest is 40-something, well, whatever. So I have a 12-year-old, 10-year-old, and then 5-year-old twins.

[00:33:41] So this point in their life story, I'm not ready to have multiple practices across the city, across the state, whatever. But I think this message is so vitally important for people that we're going to have to expand at some point. Right now, I'm focusing on just like the talk. I was trying to get the information out there. So right now, my big focus is on how do I get the same information I'm telling my patients on a day-to-day basis to the masses. And I'm using that for social media.

[00:34:08] So at Dr. E. Tiffany, I post multiple times through the week, almost every day, different questions that I have been asked by different patients and responses to those questions. And so I find that to be the way that I can grow right now to reach more people. But as far as a physical practice, this is too important to not expand. So how do you manage – so you post – would you say how many times a week?

[00:34:37] Generally, we have a video go up every day. There's a few times we've missed, but usually there's a video going up every day. And where do you post those? So it's LinkedIn, Facebook, Instagram, TikTok, and YouTube. Okay. That's fantastic. So how do you find the time – how often do you shoot your videos? I try to do them all at once. I find that that's a bit easier for me. The gal that's helping me with video editing, she's like, you need to do this while you're cooking or while you're in your car. And I'm like, oh, my gosh.

[00:35:05] I cannot imagine doing that at either place, right? So mostly because then I have to deal with all the mess my kids have made. And so I'm not sure I can deal with that. But right now I tend to do it during business hours, and I just block a chunk of time out each month in my calendar. Answer the questions. I have a whole list of all the questions people have asked because they should ask questions to their doctor, right? Right. So I capture these questions, and I never say, Sally Smith said this, right? I just say, what do you do with this problem?

[00:35:35] And here's the answer. And when I first started out, I was hitting about a minute on the clips. And then I realized, you know, people don't have that time to watch a minute clip, so let's try to keep it under 30 seconds. And doing little nuggets instead has worked really well. So do those get more views, the 30-second ones versus the one-minute ones? Yeah. Oh, they do. Okay. All right. That's interesting to know. Yeah. It's an experiment.

[00:35:59] So I do watch a YouTube guy who is a video guy, and he talks about the insect mentality of people nowadays, the attention span of a gnat. Yes. Yes. And I've heard that, but here's my pushback against that. But is it really that the attention span isn't that good, or is it our videos are that bad? Because if you have them, I'm going to pick on Netflix. A lot of people can do a Netflix binge of their favorite show, right? With a lot of attention.

[00:36:27] So I don't know if I totally buy that our attention is as bad as maybe we're not keeping the attention because our videos are bad. The videos are bad. Yeah. That's very true. So what's your favorite video to put up? I probably talk more about perimenopause than anything. One of the most interesting videos I thought was about, it was a clip talking about what's the difference between perimenopause and pregnancy because they have a lot of the same symptoms where you misperiod.

[00:36:57] You might be nauseated. You might have breast tenderness. I had a lady asked me. She kept saying, I know I'm pregnant. I know I'm pregnant. But every time I take a test, it comes up negative. I finally was like, you're appearing menopause. This is why you feel that way. And yes, she was like, what? So, I mean, it happened several months in a row. And I was like, you're not pregnant. You're not. But I know you feel like you're pregnant because these are the same signs. That's probably one of my personal favorites because that's, she's far from the only one I've heard that from.

[00:37:27] But a lot of people tend to like the cholesterol videos. They like the polycystic opharian syndrome ones, PCOS. So, I don't always know why a certain video does a better job than others. I'm not that smart enough to figure it out. But it is clear to me that certain ones have trends more than others. Mm-hmm. And then you follow the statistics and watch the whole thing through. And then, so you must have a pretty good following. How long have you been doing that?

[00:37:54] We've been dedicated doing it once a day, probably since last August. So, I don't know if we'll do this forever on every channel, right? But I committed to doing it for a year, just seeing where can I make the biggest impact? And then what does that channel specifically need? I wish I could tell you I took a more intelligent approach to this. But it really came down to what does the data show? And then go where the data leads. It would be easy to just do it in Facebook.

[00:38:22] But I don't think most of my audience is in Facebook. Most of the responses I get actually come from Instagram, sometimes from LinkedIn. Right. And TikTok, I don't even know what to do with that. I got a TikTok account simply for this purpose. And I still don't use TikTok. So, I don't know. You don't post there just because it's such a hassle? No, but like I don't look at it. I'm not a TikTok person. Right. So, it's kind of confusing to me. And I'm just like, okay, I'll post there because you're telling me to post here. But I don't know. So, Instagram is where your audience is. Do you post on Pinterest?

[00:38:52] I haven't done anything on Pinterest or any of the others like Google My Business. Apparently, you could post some things on. I haven't done that either. So, I don't know. But maybe in a year, we'll be there. Yeah. We'll see. So, but you do post on Facebook, go to. Post on Facebook. So, you're getting the most traction with the Instagram. Yes. And why do you think that is? Or you don't know? You know, other than telling you that that's where my clients apparently enjoy going, I don't know.

[00:39:22] It is a complete frustrating mystery to me. You know, if you told me these were somebody's lab values, I could figure it out. But when it comes to social media, I feel like I need a social media doctor because it is unclear to me. How do you interpret this data in a way that shows you why things do what they do? And do you do this internally in your office? Or do you have somebody else from outside who does the video editing? Post genus. I tried doing it internally and I just realized this is way, taking too much of my time.

[00:39:52] It's taking away from my patients. It's taking away from my family. So, I only do the videos themselves. If I could figure out a way how to clone myself and not feel creeped out about cloning myself, I might do that. But until then. There is some pretty good software out there where you can clone yourself. But it's still, it won't have the whole personality. It looks like you, sounds like you, but it's very. Yeah, I can't get into it. I just can't.

[00:40:19] Yeah, I've set up a couple videos with that and I thought, hmm, I just can't. It's not quite there. Maybe sometime, I'm sure at some point it will get there. But right now. So, you want to grow, but you're not sure you are, your time constraint right now because of your kid's age. Correct.

[00:40:45] And so, one of the things that's for better or worse unique about my practice is I only work during school hours. Because we're a concierge clinic, we do have people who can get, you can get a hold of me if I'm your doctor 24-7, 365. We don't use the answering service. But we are physically in the office during school hours. Which, before you ask, summer is always a pain. It just is because I'm going to figure out what to do with summer. But it is really important to me. The whole reason I made this change.

[00:41:12] So, I worked at an academic medical center for five years. Thought that that would be the life I'd have. I went out of residency, went right into an elite institution. I was like, this is where I'm going to be for life. But I realized that there was too much about other people making decisions, about how I practiced, what I did, what I did it, that I didn't like. So, I left that, went to a corporate job, did that for three years, had my twins while I was there. And one night, it was about February of 2021. At that point in my life, I had about 3,000 patients.

[00:41:41] I was working 40 hours during the work week and then a good 10 to 20 nights and weekends with four kids. And my daughter's birthday was coming up. And she thought I was on the computer shop and Amazon for her gifts. And I'm on the computer charting. And when she figures this out, she just looks at me and she's like, why do you love your job with me? And that, for me, was like the catalyst that said, we're done.

[00:42:06] And that night, I told my husband, listen, I'm either retiring or I have to find a different option. He's like, you're not retiring. Get that out of your head. Okay. Got it. Went down a different road. And by June of that year, I don't end up this practice. So a lot of what I do revolves around me being able to define the timeline. So if I'm only here during school hours, that gives me that time with my family, regardless of the size of practice.

[00:42:31] And because I'm challenging the narrative of what it means to be a doctor and what it means to have a concierge care, I've actually created more space in my life to help people with the very things they're frustrated about. So instead of me being the one that has all the wellness visits and my nurse practitioner taking care of all the chronic diseases, we totally flipped this. She does the wellness visits and then I can create a personalized report for people. I can follow them along and the people who are the sickest, I can see more often, which is what makes sense.

[00:43:00] When you have a medical degree, you should be using your license in that way. So challenging the beliefs of what we thought people really wanted and teaching them that there's a better way then allows my time to be free to do more of what I'm good at. And people, I've never done anything in my business where 100% of the people have said it's a better process. But this is that one thing where 100% of the people say this is a better process. So we'll continue to do that.

[00:43:29] And I suspect we're getting close to where we're going to have to open a second site, take on some more team members because it's just going to be cramped. And once we hit that, you know, we'll have a second site here in our town. But I can see a future where there are several sites that it won't be me seeing everybody. I'll bring on other physicians and other nurses who have a similar outlook. And I really believe that as we provide higher quality care and create value to our patients, that's what people want and that's what they'll pay for.

[00:43:58] And that's what all of us should be doing anyway, right, is serving our area of expertise. So what do you do with the insurance part of things? Right now, this is a great question. Right now, we use insurance if it's to the patient's benefit. So we have to do everything legally, okay? Here's what I mean by that. Medicare says that I have to charge every other client and owe less than what we would charge a Medicare patient. So we're in network with Medicare.

[00:44:25] That means that if you have private insurance, I can't charge you less than what Medicare would be charged. The problem is that people have high deductible plans. And within the health care community, it's not unusual for the prices that are charged to insurance companies and Medicare to be quite high, often inflated two to three times higher than what is actually reimbursed.

[00:44:49] And so if we start just doing the same thing as Medicare does for all insurances, we have found we save people money. So that's what we're doing. Even though there is some loss potential, we can't prove there's loss until it's actually happened, but there's a potential for loss by doing this because we're not charging like our peers do to the people who don't have Medicare. And then there's individuals where we're out of network with their insurance.

[00:45:13] So if I'm charging these super high inflated prices and then expecting them to pay out of network, they're paying higher than everyone else. Whereas if I charge just what Medicare charges, then it's more fair. So to me, it's really important to be authentic, to be truthful, to have high integrity, to be fair people. And so that's how we do the insurance story. We stepped out of insurance with Cigna here in our community. Cigna was costing people more to use their insurance than not to use it. So we stepped out.

[00:45:40] And I expect that we'll do that with others as time goes on because I think that's where the healthcare trajectory is headed. So how do you do concierge care with insurance? I mean, how do you charge? I'm truly curious, you know, the patients because you're having to take more time. And I guess there's certain tests in that that you want to do that just either they're going to do them and they're going to pay for them out of pocket or they're not going to do them.

[00:46:10] But you just advise them or how does all that work? So they're two separate things. There's your membership that gives you longer appointments, the personalized, personal access to me 24-7, 365. Those are things that no insurance company covers. That's part of your membership benefits. All we're charging insurance for are the professional services fees. If I could do it in a way where your membership costs covered all of that, if I could do that legally, that would be ideal.

[00:46:39] And frankly, that is what some clinics have chosen to do. The problem is you have to do, in my opinion, what's legal. And in that case, I'm in network with Medicare. So until I go out of network with Medicare, and I'm frankly not willing to do that to all my older patients, it changes it for everybody. But the crux of this is you have to follow Medicare's lead here. And Medicare says you can't charge anyone less than their patients. So we have to charge something for the professional services.

[00:47:09] But we do tests that aren't covered sometimes. You're right. And those tests, people do choose to be out of pocket for them. Health coaching, for example, we have three board-certified health coaches. That's not covered by insurance. So that's out of pocket. But we let people choose. And we let them figure out what they think is important and what's valuable. Obviously, we're not going to recommend something that we don't think is medically helpful. I don't want to just tell everybody, for example, they need IV fluids once a week. That's kind of crazy. That's obvious scale.

[00:47:38] But there are people out there that take advantage of folks. And so a lot of what I want to do is educate on what are the facts, what is true, why do we do the things and have a good medical reason for it. So tell me, when you stepped out from being under this umbrella of a health care system, hospitals, and then going out and starting,

[00:48:04] and then you have your rent, and then you have some staff, and you have all this equipment, and you have utilities, and you've got to get this furniture and decorate your office. And there's a lot of cash going out. And what was that like emotionally to go through that? And would you recommend it for somebody else? So I would 100% recommend it for the right person.

[00:48:29] If you are the type of person who can make decisions quickly, who's not going to ruminate on decisions that didn't go the way you thought they would go, who's willing to take risk, this is a great option. It would be a terrible option for my better half. He does not like making fast decisions under the wire and taking risk. He will do all of those things if he has to, but he would not choose to.

[00:48:53] And I think there's a lot of people who would much rather not be the decision maker, not have to stare down a bank account and say, okay, make or die, right? But I think it also brings into clarity why you're doing what you're doing. And then when you have that kind of clarity, it's very easy to attract the type of person and what you can offer to them. In our case, we actually invited all the 3,000 patients I had before. I was able to invite all of them to come with me.

[00:49:23] And I think maybe 150 did. So I had a little bit of a buffer. I wasn't starting from zero. And then I could grow from there. But for a long time, it was just the nurse practitioner. We answered the phone. We did the billing. We did all the collections. We did all the vital signs for ourselves. We did everything. Because we just couldn't afford not to. We still don't have a receptionist. And it's the funniest thing when you go into a medical office and you're like, wait, there's nobody at the front desk. Why? And then out with them is your doctor or your nurse practitioner.

[00:49:53] They're like, come on back. You know, that's just not what folks expect. Yeah. We made a pretty substantial pivot. More than 50% of our clinic visits are actually online. And what we have found said, pandemic or not, people enjoy that flexibility. Right? If you don't have to leave your job or find child care, come in, wait to be seen, sit in the waiting room for who knows how long with who knows what germs. And then be seen, wait some more, leave, wait some more. Nobody likes that.

[00:50:23] So virtual care was an easy change for us. And we did that starting day one. But through the pandemic and following probably 60, I think 63% was the last number I saw of our visits being virtual. That is a lot of visits to be virtual. Yeah, that's a lot of visits. You know, if this was a national platform, that could be different. You'd expect all of them to be. But we're talking about people in my city, 60-something percent of them do a virtual visit.

[00:50:49] And if I don't need to look in your ears or listen to you breathe, that's probably okay if we're just talking about data and I'm educating you. So I think we're going to wind it up right there. This is really enjoyable. Thank you for joining us on The Holistic Entrepreneur. Visit our website at holisticentrepreneur.org for more resources and information about today's guests. Subscribe wherever you get your podcasts.

[00:51:13] Until next time, I'm Zane Myers, and we'll continue exploring the intersection of holistic health and entrepreneurship.