I thoroughly enjoyed my conversation with Dan Kalish this month. He’s a gold mine of practical, inspirational advice around building a successful, sanity-supporting, lucrative practice in functional medicine. In this podcast, you’ll hear Dan talk about:
- The Deer in the Headlights Moment: Transitioning into FxMed from a conventional medical practice. You can do it!
- Plan it out. And plan it out again
- Have a niche, at least during the early transition period. Broaden later
- Start with a patient-centered (rather than a clinician-centered) focus
- Know your personality, what makes you passionate
- Marketing: Pick what lights you up and do it. It’s not “one size fits all”
- Stick to it! Consistency in marketing is essential
- Free consultations or coupons: Do they work?
- Designing patient-adherent treatment plans, a few general ideas
Dr Daniel Kalish, CEO and Founder of the Kalish Institute
Dr. Daniel Kalish is dedicated to teaching doctors Functional Medicine philosophy and practices. Through The Kalish Institute’s educational programs he has trained over 1,000 practitioners worldwide in The Kalish Method, which solves patient challenges through a proven lab based approach. Recently, a research study published by two Mayo Clinic researchers confirmed the efficacy of the Kalish Method showing significant improvements in GI health and quality of life in the study participants. Click here to view full research paper.
EDUCATION
Dr. Kalish studied at the University of London and conducted research with biochemist Dr. Robin Monroe at Cambridge University. His studies led him to mentoring with renowned psychiatrist R.D. Laing, as well as John R. Lee, M.D. a pioneer in the use of progesterone and to teaching collaborations with leading endocrinologist Diana Schwarzbein.
AUTHOR AND AUTHORITY
He is the author of three books, “The Five Pillars to Building a Successful Practice,” “The Kalish Method: Healing the Body Mapping the Mind” and “Your Guide to Healthy Hormones” and is a frequently requested speaker for integrative medicine conferences across the United States.
Website: http://kalishinstitute.com/
Contact: info@kalishinstitute.com
Podcast sponsored by Designs For Health
Designs for Health is a professional brand, offered exclusively to health care professionals and their patients through referral. By providing comprehensive support through our extensive line of nutritional products, our research and education division, and our practice development services, we are able to maximize the potential for successful clinical health outcomes.
Kara Fitzgerald:
Hi everybody. Welcome to New Frontiers in Functional Medicine. I’m your host, Dr. Kara Fitzgerald. Today we’re going to talk about all things practice building. Either you’re a new clinician creating your first functional medicine practice, or you are a conventionally trained doc just jumping into functional medicine. What do you do? How do you make it work? We have got one of the world’s experts in this arena on the podcast today. I’ll be talking to Dr. Dan Kalish. Dr. Kalish has literally educated thousands of folks in making the transition to a successful, thriving, stress limited practice. He’s dedicated to teaching doctors of functional medicine philosophy and practices.
Through the Kalish Institute’s educational programs, he has trained over a thousand practitioners worldwide in the Kalish method, which solves patient challenges through a proven, lab based approach. Recently, a research study published by two Mayo Clinic researchers confirmed the efficacy of the Kalish Method, showing significant improvements in GI health and quality of life in the study participants. I have this paper for you. It’ll be on Dan’s podcast page as a PDF that you can download. It really is quite an exciting study.
Dr. Kalish studied at the University of London, and conducted research with biochemist Dr. Robin Monroe at Cambridge University. His studies led him to mentoring with renowned psychiatrist R. D. Laing, as well as with John R. Lee, MD a pioneer in the use of Progesterone, and to teaching collaborations with leading Endocrinologist Diana Schwarzbein. Dr. Kalish is also the author of three books, including The 5 Pillars of Building a Successful Practice, The Kalish Method: Healing the Body, Mapping the Mind, and Your Guide to Healthy Hormones. Dr. Kalish is a frequently requested speaker for integrated medicine conferences across the United States. I’ve actually been chatting with you quite a bit lately, Dan, and I appreciate the amount of time and energy you’ve put into building this really wonderful resource for clinicians transitioning into functional medicine. Thanks so much for being on the podcast today.
Dr. Dan Kalish:
I’m so glad to be here, and help spread the word.
Kara Fitzgerald:
Absolutely. Let’s get right to it. A clinician is transitioning to functional medicine from a standard medical practice. I’m seeing this, as an IFM faculty, we’re putting a lot of attention around to building these support bridges. Any advice for making this big, often scary, leap to making a functional medicine practice work?
Dr. Dan Kalish:
Yeah, I think the biggest thing that we see, and a lot of doctors are just starting this transition when they sign up for my various training programs, so this is probably the most common situation that we’re in when we’re working with doctors, and I think the universal … What would you call it? Kind of gestalt of this, the universal big picture of this is that the person has just complete fear, concern, about losing everything, and that it’s not going to work, and it’s going to fail, and they just don’t see how all these pieces are going to fit together. People are just sort of frozen, like a deer in the headlights moment, where they know they have to do this, every fiber of their soul is screaming to them, “You can’t keep going in this conventional medical situation, because you know you’re not helping people in the way that you want to, or at the depth, the level that you want to.”
Then, there’s this promise land over there, which is successful functional medicine land, and making that leap is almost impossible for people to do without some kind of really significant support. I’m like the guy on the other side of the shore saying, “Hey, over here. Happy functional medicine land. You can do it. We’ve trained a thousand people to do this. I know what you’re going through.” To just kind of be that beacon of hope that’s to say, “Hey, you will fail if you don’t get some help, because this is a really hard thing to figure out, but there are predictable places that people fall apart. We’ll tell you what they all are.” I mean, you and I can talk about these today, as much as we can. Just give that sense of encouragement that, “Hey, you know what? You can totally do this. If you could get through medical school, you can handle this one, too.” It’s just a big unknown.
Kara Fitzgerald:
Yeah, absolutely. I know. I do encounter it routinely, and again, we’re doing our best in the functional medicine space to help bridge it. Give me a couple of the predictable places you see this breakdown.
Dr. Dan Kalish:
The first, and initial issue, is that people don’t create a plan ahead of time that they then execute. It’s very vague. They know what they’re doing in their current medical practice, but what they’re trying to create is sort of based, probably, on an amalgam of the various teachers that they’ve studied with, and looking at their practices, and seeing how they work, but you can’t do that. If you think about it, it’s like opening a restaurant. If you were driving around, let’s say, we were talking about New York earlier. Say you’re in New York, and you go visit twenty restaurants, and then you want to open your own restaurant, but you don’t create a menu, you don’t hire chefs. You just have, in your mind, this idea of a restaurant, and then you rent a space, and then you kind of try to figure it out as you go. Well, clearly that restaurant would fail, right?
We want to have people planning out everything that they’re doing, every service that they’re going to offer, every type of patient they want to try to attract, how their marketing’s going to work, how their sales process is going to work. Everything has to be laid out in a plan, obviously, and then you can execute to that plan, but we see very few doctors that have a detailed business plan as they’re starting a business. Right off the bat, they’re starting from a place of almost … It’s going to make it harder than it needs to be.
Kara Fitzgerald:
Yeah. That’s a great analogy, using the restaurant idea. I love organic, but I want a little Japanese food in there, and I’m going to throw some Chinese, and maybe we’ll do some Italian, because anybody who’s going through the functional medicine training, they’re being exposed to a lot of different clinicians with various areas of expertise. All of us are sort of birthing our practice model in different ways, so if you’re grabbing a little bit of all of that, I could see it would be extremely overwhelming. I’m imagining that part of this work is establishing your niche, establishing your menu, as it were.
Dr. Dan Kalish:
Awesome. Thank you.
Kara Fitzgerald:
Any pointers to developing that?
Dr. Dan Kalish:
Yeah. It’s a little counter-intuitive, because within functional medicine, on a clinical side, we know everything causes everything else. You can’t really just pick one thing, and just say, “I’m going to specialize in gluten free diets,” because you know that that drags in autoimmune, and it probably is going to influence gut pathogens. Clinically, it’s kind of a mess to try to sort this out, but front, if you look at it … In other words, if you try to say, “I’m going to create a niche within functional medicine, like I’m just going to run food allergy tests,” or something, that would be doomed to fail. You can look at the niche from the way that the customer, the patient, looks at it. We’re always looking at things the way the clinician, or doctor, would see them, and we really rarely put ourselves in the patient’s shoes.
Patients really don’t care too much about what labs you use, or what techniques you use. They certainly don’t care about supplement companies or anything like that. They’re just interested in a certain benefit, and receiving a benefit from what the doctor’s offering. The niche has to be one hundred percent patient centered, meaning that, as a person who’s never been to a functional medicine seminar, knows nothing about it, just has a complaint. How is that going to work? I just gave you some examples, some great ones, and some wacky ones, just to get people’s thinking going.
One of the greatest first niches I ever saw, this was one of my students ten, fifteen years ago, he took my training program, this was true story, and he decided to create a niche around what his problem was, that we cured during the training program, which was H. pylori. I was thinking, “That is a dumb idea.” I mean, honestly, I didn’t say anything, but I was like, “That’s a pretty dumb idea.” You know what? He had a booked practice in like two or three months, because it turns out, there’s a lot of people that have H. pylori that aren’t getting the problem solved.
Kara Fitzgerald:
Geez
Dr. Dan Kalish:
It was a brilliant niche. That kind of taught me, “Okay, it could be a really narrow niche.” It wasn’t even GI, right? It was just H. pylori. That was it. Crazy niche. I love this one. Another student of mine in New York City, again, I thought this was ridiculous, but it worked beautifully for him. He created a niche just working with women who are about to get married.
Kara Fitzgerald:
Really?
Dr. Dan Kalish:
What a wonderful idea. Apparently there are a lot of women in New York City that are about to get married, and what are they? They’re highly motivated to look their best, to fit into their dress, and you have a six month or a yearlong window where they will do anything you say to make themselves beautiful, and sexually active, you know, high sexualized during their wedding period of time. That’s an example of kind of a crazy, silly niche. It could be something narrow.
I mean, common ones, obviously, would be working with pregnant women, working with kids, working with the elderly, working with professional athletes, working with Hashimoto’s patients only, working with chronic, long term GI problems only. You can dish it out in a variety of different ways depending on, I think the most important thing is, where your passion is, and what you’re the most interested in, because that’ll come across to the patients that you’re marketing to.
Kara Fitzgerald:
I’m assuming that once you leap in, and you’ve designed your initial marketing plan around that narrow focus, that it’s going to naturally broaden. Is that true, would you say? Is that guy still addressing H. pylori only, after fifteen years in practice?
Dr. Dan Kalish:
It depends on the doctor. A lot of us would get bored if we just did H. pylori every day, because our personalities are stimulated by complexity, by problem solving, by learning new things. I think there’s different sort of personality types. Other doctors are just as happy to pick as narrow a niche as they can, let’s say fertility, and just work with fertility patients for, you know, a twenty, thirty year period of time. I think the answer to that question is more dependent on what the doctor’s interest level is, in terms of more stimulating, new learning, new protocols, and that kind of thing, versus just doing the same thing over and over again.
From a business perspective, if you’re interested in making money, then obviously sticking to the narrower niche is better, but if you lose your passion for it, what’s the point right? We’re not doing any of these things for the sake of money. We’re doing this so that we can be delivering the services that we want to as healers, and so I think really, we see that the doctors are always successful if they stay true to what their purpose is, and what their intentions are in terms of bigger things, like what their life goals are. Why are they here? Why are they on the planet in the first place? For somebody that might not be [inaudible 00:12:00] narrow niche. It might be like you said. Maybe you start with pediatrics, and then you broaden it out to adults with ADD and ADHD also, or something like that.
Kara Fitzgerald:
Right, right, right. I can see that. I mean, really, you’ve brought up some wonderful points. Just, what is your inner guidance? What is your purpose moving through that? Having a clear definition, a clear vision, a very clear plan, and then if you do want to expand, like many of us are interesting in doing, because functional medicine really is systems medicine at the end of the day, you can do that, once you’ve established yourself. It seems to me it would be pretty easy, if you’ve got a bunch of H. pylori patients, they’re all going to probably have some degree of allergies or food sensitivities, because they’re not digesting well. They’re probably a bit hypochlorhydric, and it would be fairly straightforward to expand that space.
Dr. Dan Kalish:
Yeah, but here’s the thing with the niche, like H. Pylori, or like fertility, is that that’s just what brings the customer in. Once they’re in, then the doctor’s going to say, “Hey, we have this H. pylori program, we already know that. Your previous doctor has the testing, but let me tell you how this really works. If we don’t clean up your diet, and get the inflammatory foods out, we’re not going to be able to treat the H. Pylori. Because H. pylori problems cause all kinds of toxicity issues with your liver, we got to test and correct your liver. Whoops, there’s probably a lot of food allergies,” you know. What brings that person in, that one thing that brings them in your door, you’re still then able to execute on all the functional medicine, labs, and workups that you would want. Obviously, what works just to treat H. pylori in isolation, right? That would be an unsuccessful practice.
Kara Fitzgerald:
Yeah, absolutely. You’re automatically moving into systems, but you’ve got a funnel, so you enter at the narrow end, and then you expand into a systems approach from there. Is that what you’re saying?
Dr. Dan Kalish:
You have to. Yeah. That’s the beauty of it. That’s what I’ve seen as this dichotomy because you and I are thinking system approach, and the idea of having a niche just seems ridiculous, because we know that even for everyone would H. pylori, or everyone with Hashimoto’s, we’re going to have to go through all the systems. If we market ourselves as systems biology oriented functional medicine clinicians, and you actually say what’s going on, then patients immediately get lost. They can’t relate to that, but they relate to the pain of H. pylori, or the pain of not being able to have a child. That’s what I’m saying. You kind of want to speak their language to bring them in, but once they’re in, our plan is going to be to do a full battery of functional medicine workups and treatments, even within a niche.
Kara Fitzgerald:
That makes really great sense, and it also feels infinitely less overwhelming than what I would imagine a lot of new clinicians are thinking, “I need to market that I’m practicing systems medicine.” It’s entirely daunting. That’s daunting for the physician. That’s daunting for whoever’s going to be receiving their media, or reading their advertisements. Yeah, it’s too much. Let me just talk to you about that a little bit, and then we’re going to talk about some specific approaches to patient care that you recommend. Marketing is a huge deal. Marketing locally, doing print ads, getting active in social media, doing Facebook, blogging, and on, and on, and on, and on. I mean, it’s a big, big world. How are you guiding folks in the marketing arena?
Dr. Dan Kalish:
That one, and this is why I do a lot of one on one coaching, you know. I was thinking about this before our call. I’m the one that actually has coached the thousand people, myself. There’s no assistant teacher person here. I’ve interacted with each one of these doctors, and I’ll tell you one thing is that there’s no way to do a generic marketing plan.
Some doctors love to write, and they’re good writers, there’s a blog in your future. Some of them are just charismatic. You put a camera in front of them, and they just light up. They’re like George Clooney, or Julia Roberts, or something on camera, and there’s your video blog, kind of Youtube posting kind of person. Some of them are great in person. They love to speak to groups, and then we get them doing local seminars to patients about given subjects that are within their niche.
Really try to focus on what’s going to be an enjoyable activity for the doctor to do, because no matter what it is, whether you’re posting Youtube videos, or you’re doing a blog, or you’re going around doing talks, if you’re consistent, and every week you put three, four hours into your marketing efforts, over the course of twelve or eighteen months, you’re going to build up a following. That will start to create it’s own momentum.
What happens ninety- nine percent of the time is the doctor learns about social media, they hire a social media person. They just don’t like to write. It’s just not their thing to be posting these Twitter, Facebook, Youtube, Instagram things. It’s not genuine to them, so it doesn’t work. Then again, you put them in a room with twenty five people at some yoga studio that’s talking about female hormones, and then they just get five or six patients to sign up just because they’re really good in person.
The idea is that, with marketing, it’s way simpler than people think. You don’t have to spend a lot of money on this, either. It’s just the consistency of the message over time, that within twelve to eighteen months, consistently pays off. It doesn’t take more than a couple of hours a week. It’s not a huge time commitment for the doctor, either, and it doesn’t help just throw a lot of money at it. Each one of us, as a practitioner, really is our own brand. Like the Kalish Institute, it’s pretty obvious, right? Kalish, it’s me, it’s my name. My teaching is me. I’m the brand that I’m selling, and for a doctor in practice, Dr. Jones, her brand is her personality, and how she is perceived by the people in her community.
Kara Fitzgerald:
She needs to just jump in and express that. You said consistent, and also that it takes time. That’s certainly been my experience, just plugging along, putting the content out there. I have a lot of interesting newsletters come in my box. I mean, some of them are from the integrative space, but since I’m a bit of a science geek, I have newsletters from various labs that throw out new research, and so forth. Then, I just kind of keep my eyes open for that. A lot of those will turn into posts. Maybe we’ll make them long enough, a couple paragraphs long, so we’ve anchored it to the website. I’ve seen it. I worked behind the scenes for most of my career. I’ve always had a clinical practice, but I hadn’t directed my attention to my own sort of brand building, as you say, until the last couple of years, and how you’re articulating it has been true in my experience. You just have to keep doing it, and keep doing it reasonably consistently, and within a structure that is doable, not biting off more than I can chew.
Dr. Dan Kalish:
It’s the same, probably, for all aspects of life in general. These simple truths are just what they are. They’re simple truths, and they’re universal. It’s not like Youtube is biased towards people who are in Nebraska, or is promoting people who are in Chicago. It’s almost like there’s a formula we just need to follow, and if you can stick with the script, then this predictable result will occur.
Kara Fitzgerald:
The larger internet social media space is pretty obvious. There’s Twitter, and Instagram, and Facebook, and so forth, and Youtube. Locally, you mentioned giving talks. Anything else about local marketing? Any other way people might reach out locally?
Dr. Dan Kalish:
You know, a lot of the things that you would think of in terms of marketing are pretty expensive. Whether it’s print ads, newspaper, magazines. Whether it’s TV spots, having a little radio show, or TV show. Most of the doctors who are starting out, it really doesn’t accelerate the growth of the practice to spend five to ten grand a month in marketing. What works a hundred percent of the time, in my experience, is if you just start doing public talks. It could be at the local Whole Foods, yoga studio, massage school, women’s groups. People, corporations, there’s always groups there looking for hour long lunch talks.
We even have some doctors that do a paid version of that, where they pay a fee, a pretty reasonable fee, and then this marketing company will gather like thirty people together for a dinner/talk, where you can pitch your services. There’s really affordable ways to do that. We find that, also, if a patient sees you in person, and is able to ask you questions, kind of gets a really solid sense of who you are as a person, that almost pre-sells them on coming in to your practice, either right away, or when they eventually have a problem where they need you.
I think that in person presence, and having a circuit, where you go around. When I was in San Diego, for many years I had a circuit. I did a community college talk twice a year. I had a women’s group. I had a church group. I had a yoga school. I had a massage school. Just like Ulcerative Colitis Crohn’s Support Group of San Diego, and the Celiac Group of San Diego. I had like six, seven groups, and I would just do a talk once a month with one of them, and always get four, five new patients from doing that. It didn’t cost anything, and it was just kind of a way to educate people. Purely educational talks, no sales or marketing within the talks, just purely educational about a subjectof interest to those patients.
Kara Fitzgerald:
Let me ask you one more question in this arena, and then we’ll move on to some of your thoughts around patient care. What do you think about coupons? What if you’re at one of these talks, and you offer some sort of discount coupon, or you have that on your site. Is there any value to that?
Dr. Dan Kalish:
Absolutely. It has to be part of your business plan. Many times we see doctors offer discounts, or coupons, some kind of concierge service, or yearly fee, and they haven’t thought out the financial ramifications of it. You can do simple things like free fifteen minute consultations, something like that, where it’s very clear how much of your time it’s going to take, and how much of a potential loss of revenue you’re going to have. One of the practitioners in my training program now, this fellow Justin he just told me this a few weeks ago. He converts almost ninety percent of his fifteen-minute consult people, that are free, convert into a paid patient right away.
If you have the system set up properly, and you’re screening people, and it’s having some way of qualifying people who sign up for that, not just letting it be anyone who’s on the internet, that can be super successful. A lot of times, patients just need that last confirmation. They’ve seen your YouTube videos. They’ve checked out your website. Their friend told you you’re good, and that last in person meeting is just enough for them to go, “Okay. I want to do this now.”
Kara Fitzgerald:
Right, right. We offered, at one of the clinics I worked at when I was in my residency and my post-doctorate, we actually offered a mini-lab. People would come in and discuss their results. It had a really good price point with it, for it, so it didn’t cost the clinic much to do. That was incredibly effective, in my observation.
Dr. Dan Kalish:
Yeah, people always want a deal, you know? You have to be a little careful, because you don’t want to always get patients that are looking for bargains, because they oftentimes turn out to be patients that aren’t so great for the long term. It’s kind of a balance there, I think. You don’t want to get people that are just discount shopper people. It’s more you want to qualify it. That’s why I’m saying Justin has a way of making sure that those free fifteen minutes go to people who are screened in some way, so he knows that it’s very likely that they’ll continue on. They’re not just trying to get fifteen minutes of advice, and then go do their own thing. They’re wanting to make sure this is a good first step for them.
Kara Fitzgerald:
Okay, so you’ve got this patient in your practice. You’re bringing them in. You’ve got your marketing game happening. At that first visit, where you’re really trying to engage the patient in what you have to offer, how do you do that? What kind of information does the doctor need? What does that dialogue look like to establish that connection, and to get the patient excited about this wellness journey?
Dr. Dan Kalish:
It took me about ten or twelve years, and maybe five, six thousand patients to figure out what I’m about to say. This is not necessarily intuitively obvious, but I actually teach this as a subject in my practice management class. This is super important. I call it, for lack of a better term, I just made up a term, I call it the condition description technique. What it means is that the patients coming in with a condition, let’s say Hashimoto’s to make it easy, and you have to somehow describe to them how functional medicine, which is this huge world of complexity that we all understand systems oriented, how that whole huge complex world is directly related to their specific condition, and you have about five or ten minutes to do that.
The art of that skill is understanding what the patient’s viewpoint is. Let’s say they have Hashimoto’s, and they’re tired all the time, and they’re overweight. You take that information, and you describe to them how functional medicine specifically can address their top concerns. Once they see how effective your program can be, I’ll give you like a two second example. Let’s say it’s Hashimoto’s.
You would say, “We frequently see Hashimoto’s strongly related to gluten, and to other chronic GI issues, in addition to inflammatory immune destroying foods, you know, there can be pathogens in your gut. I really think we should do this testing that looks at foods and pathogens in your gut, so we can address your Hashimoto’s more deeply. Autoimmune cases in general, we find often involve liver detox pathways, not always, but we often see there’s problems with the liver being able to get rid of toxins and antibody antigen complexes. I really think we should test your liver pathways, and run this organic acids profile. We almost always see energy deficits. I know you’re tired, kind of makes sense with Hashimoto’s, so obviously in addition to the thyroid workup, we may want to look at adrenal function, at mitochondrial energy production, might want to run some cortisol levels, and an organic acids test to look at the mitochondria.”
In a couple of minutes, you kind of describe to them how your hormone, or GI, or organic acids testing is specifically related just to their condition. You don’t try to describe the whole thing, because that’s overwhelming and they won’t care. You just try to describe what you’re doing, your system’s biology, your system’s approach, only as it relates to their top complaints. That sells people immediately, because then they’ll walk out of your office, go to the front desk, and say, “Wow, I want to test my cortisol, for sure the foods and the pathogens. What’s that organic acids thing? Give it to me. Give it to me,” because they see the test as directly addressing their problem.
Not as a general solution for all problems, which we know it is. Functional medicine can solve anything, from toenail fungus to heart burn, but we just want to focus that patient on how we’re addressing their top concerns with the labs. Once I perfected that ability, I could really sell a whole series of labs to just about anyone, but the way I describe the value of the tests is different. That patient has to see that there’s a perceived value to them, firstly. Not that you’re excited about it as a doctor, but that they’re excited about it, because they see the value to them.
Kara Fitzgerald:
Absolutely. One of the things that I do, because I’m practicing within the Institute for Functional Medicine’s model, that after I finish my intake, this is not in fifteen minutes, but I’ll walk them through a timeline, sort of like the sequence of events that I’ve observed, that I’ve gotten in their history, that influenced why they are where they are today. I’ve heard them. I’m connecting the dots through the course of their life, and then I walk them through how we’re going to investigate, and how we’re going to begin to reverse it. This isn’t a full intake, and my first full office visit is ninety minutes or longer, but that final segment of articulating what’s going on with them, hearing them, understanding, and then walking them through that journey to wellness, giving them a thumbnail on what we need to do.
It’s true, Dan. It’s incredibly inspiring. Indeed, in my practice, too, patients are excited about the labs, because they want to get to know themselves. I often say we’re going to look under the, “biochemical hood,” or, “metabolic hood,” and see what’s really going on. It is. It’s quite inspiring. These are specialty tests, a lot of time. I certainly run insurance covered testing, and I actually do as much of that as I possibly can, so there’s usually no out of pocket expense to patients if they’ve got insurance for those, but I’m also running, as you say, organic acids, or I’m doing a comprehensive urine hormone, or I’m looking at some specialty food sensitivity panels, adrenal, and so forth.
How do you think about pricing with that? I know, I guess you get patients enrolled, because you’ve talked to them about how you’re going to unlock their health issues. How do you get them on board with the pricing, and how do you think about pricing?
Dr. Dan Kalish:
Well, this is a hard one. Let’s go back to how doctors feel about money, is really the problem here. I grew up in Berkeley, California. My dad was a professor. When my sister decided to go to law school, my dad was like, “Okay, that’s great, but I’m not paying. You go get a PhD in history, like I wanted you to, fine.” My family was like anti-corporate, anti-business to an insane degree. You can imagine a bunch of people in Berkeley in the ’60s, who were academicians right? I grew up with this whole money is bad, really the root of all evil is corporate greed, and the idea of profitability was a hundred percent a negative concept.
Just look at the situation that we’re in, and I see this in different degrees in most doctors. They feel a little guilty about making money from people who are suffering, which is understandable, because in a normal culture, as a healer, we wouldn’t have to be running a small business. We’d have a hut somewhere, with some herbs and roots, and people would bring in a chicken, and we would heal them, and then we would get the chicken. We’re in a culture where we have to do this exchange through money. It’s just the way that it works. If we devalue our services, or the lab costs, or the supplement costs, then the whole concept falls apart for a couple different reasons.
One is that the doctor’s business won’t be profitable, so then they’re going to end up overworking too many hours of work. They’re going to burn out, all the time, because they’re not charging enough. The second thing that happens is that if the patient thinks they’re getting a discount, or if the patient doesn’t see the value of the testing, and the supplements, and the value of the doctor’s time, then you’re missing out on the most important part of the healing process, which is that belief that this is going to work, whether you want to call that placebo, or you want to call it the energy of healing, or spiritual healing, or whatever that is where people believe in you as a healer, and doctor, and that is, as we all know, a large part of why people get better.
In fact, in my mind, in some ways, that’s the main reason why patients get better. They get a sense that they can get better from us leading them in that direction. The labs are just kind of instructional, for a lot of different reasons. What I’m trying to say is, the more you charge within reason the better. You don’t want to gouge people. That’s just socially inappropriate, but we charge full price for my time. I charge four hundred plus an hour. We don’t ever discount supplements. People have to pay a full amount for the special supplements that we carry. The lab testing, itself, is a relatively minor fee, because they usually only have to pay for all the specialty labs up front once.
Obvious yes, if their histology workup comes back clean, we’re not going to retest them over and over unnecessarily. They’re not ordering new labs every month, but there is this initial upfront cost of the tests. If you looked at my clinic, my average patient who’s doing comprehensive hormones, all the GI workups, and organic acids profile, it’s around a thousand bucks. I can’t even buy new tires for my Audi for that much. Certainly, even if someone’s not driving an Audi, if someone’s driving a 1990 Corolla around, even if the transmission fails, it’s a thousand, two thousand dollars. Any kind of significant car repair is in the range that we’re talking about.
In terms of our culture, it’s not a lot of money, is what I’m trying to say. We, as doctors, often see it as this, kind of cringe from the idea of it being so expensive. I think that once the practitioner is clear on the value of what they’re delivering, then it really makes a difference. One of my teachers said this a long time ago, this guy named Paul, and this completely changed my view of what I charge people. He said, “Dan. Why don’t you charge people for the end result, and have them pay when that result is achieved?”
For example, fertility patient comes in. I would say, “Okay, Jane. Sign this contract. Everything is free, but if you get pregnant, and have a baby, what’s that worth to you? What’s that dollar amount worth to you?” I mean how much would she put down? Not five or six thousand dollars, which is the actual cost of my services and all the supplements. She’d probably put down what the fertility treatment costs, thirty or forty thousand. We got to see the value.
Kara Fitzgerald:
That’s right. That’s absolutely right. People are coming to us either because they’ve been down many paths before, often, and they’ve exhausted their resources time and time again. That’s extremely true. I was going to talk to you about that. This investment, sort of the psychology of all of this from the patient’s point of view, when they get this, it’s A, they’re fully invested in the process, and I think that there’s definitely some gratitude for finally having a clinician sitting in front of them with clear direction. Let me just ask you now, what about folks who decide they want to stay in the insurance model, and accept health insurance in their practice? Any comments for those clinicians? Do you work with those clinicians?
Dr. Dan Kalish:
You know, there is a very, very few in that category. Within my training program, I try to connect them to one another, because they’re going to have their own, pretty unique challenges, especially if they want to stay one hundred percent insurance. Most of the people that we’re working with are either trying to transition to all cash, or trying to build a cash practice a couple days a week that’s going to run in parallel with their insurance based practice. My general experience is that if the doctor’s in a place where they want to do one hundred percent insurance, and we try to coax them out of that position, and say, “Why don’t we just do Fridays cash, and let’s just see how that goes for a year or two?”
Gradually, over time, every example I’ve ever had, once they see how much easier it is, and how much less work it is, and how much better their patients results are, they’ll gradually kind of shift over. Typically, end up maybe fifty percent cash, fifty percent insurance. We don’t get a lot of doctors that … It’s just very hard to execute this model in an insurance climate, without the physician burning out. Not that the patients aren’t going to get great services, because they can, but the amount of time that the doctor has to put in is not sustainable or realistic.
Kara Fitzgerald:
Yes, that’s right. That’s right. I think, definitely in my experience, having a cash based practice, the continuum of an individual’s readiness to change, they move through that once they make that financial investment. They’re much more ready to jump in, and do what they need to do.
Dr. Dan Kalish:
I think there’s two other kind of corollaries to that. One is that there is a surplus right now, in America, of patients who want to find doctors to do this with, and want to pay cash. There’s no shortage of people who want to do cash. That’s number one. The only reason that you would be left wanting to do insurance would be because you want these services to be available to people who can’t afford them, because it’s expensive, even though maybe it’s only a thousand dollars for labs, a lot of people don’t have a thousand dollars, and never will.
If you’re of the mindset that you need to stick with insurance because there’s not enough cash patients out there, I would dispel that completely, because there’s more patients than any of us can handle. I have a two or three month waiting list. There’s more people out there than we can handle. If you want to stay with insurance so that it’s more affordable, I would strongly suggest you …. All the smart doctors do it the exact same way. They set up a cash practice, and then they designate a certain percent of their practice for people who can’t afford their services, ten percent, twenty percent, thirty percent, fifty percent, whatever you want it to be.
Then you have certain days of the week, or certain numbers of patients that you’ll take on, where you are taking on people who can’t afford the full services, and figuring out a way to … You can’t necessarily discount fees or discriminate, but figure out a way to put them through your clinic in a more affordable way. You can still work with people whom are underprivileged and can’t afford our care, but I think it’s better to control that, and to leave insurance companies out of it.
Kara Fitzgerald:
Yep. Amen. I have found, because I do that in my practice, as well, and I’ve found certain lab companies, and even supplement companies, can assist us in those cases. All right. Going back to that initial patient visit. You’ve gotten them excited, and they’re onboard with the process. What kinds of issues might we want to identify early in the process, with the patient? What special issues might they be facing that we want to look at early?
Dr. Dan Kalish:
From the business side or from clinical side?
Kara Fitzgerald:
I’m sorry, we’re hopping back into clinical.
Dr. Dan Kalish:
On a clinical side. I think about it, I can combine the answer to that one, and try to throw in some business concepts, too, because I think, in a way, they’re the same. My favorite example of this is my dentist. Dr. Henou is my dentist. I’ve been seeing him since I was like six or seven years old. He sold his practice to Dr. Mahardy mean, I love her. She’s like my mom. I’m probably going to see her as a dentist until the day I die. One of the things their office does really well, and they have since I was a little kid, is they remind me to follow up, and follow through.
If I don’t get my teeth cleaning scheduled, you know, I’ll kind of sneak out of there. I schedule the teeth cleaning, but then I know I’m going to cancel it, and then I don’t reschedule it. They have a follow up system, so they start texting me, “Hey, you haven’t had your six-month cleaning. You better come in.” I don’t look at those follow ups as marketing or sales, which is really what it is, I just think fondly about Dr. Mahardy, and I think, “Haven’t seen her in a while.
Yeah, my teeth really need a cleaning. I’d better go in.”
One of the, I think, the most common, most important way that we see clinicians fall apart is not on the startup, because most of us are pretty good that first couple of weeks, a month, or two. We’re good with people. We enjoy our job. Patients get that, but the follow up that we see in practices is from non-existent to horrible. Meaning that, are you sending out six month reminders to every patient to do a follow up, to talk with you, to tune up their diet, to make sure they’re exercising, to make sure their meditation practice that you recommended is on track?
Are you doing follow ups even in the beginning? When you sell that first supplement program to them, you need to follow up a week or so before you know those supplements are going to run out, to make sure that they reorder and they stay on track.
I think the lack of follow up is almost universal in every practice that we analyze, and that leads to two big problems. One is, it leads to poor patient outcomes, because as you know, you can’t just someone thirty days of a bunch of vitamins and their whole world is going to change. They need to take supplements, and do these diet and lifestyle changes over long periods of time, months or years, in order to get the results that we’re all looking for. We don’t get the best clinical results without the good follow up, and of course, the business model falls apart as well, because you’re losing out on a majority of your potential sales by selling every new patient a month or two worth of services, and labs, and products, but not capitalizing on the ongoing sales, which is where the vast majority of the profit for the business comes from.
It’s the exact same thing with Mahardy. I don’t think less of her as a dentist, or as a person, because she does great follow up. Again, as a patient, I don’t even perceive it as sales and marketing, which is exactly what it is. I see it as her doing me a favor to keep me on track with my dental health. In functional medicine, patients perceive this the same way. They’re like, “Wow. Kalish’s office e-mails me every six months. It’s not like he’s stalking me. He cares about my diet, and whether I’m saying on the supplements, if the program’s working.” Follow up is really, I think, the biggest breakdown point that we see.
Kara Fitzgerald:
Speaking of follow-up, and you’re right, that’s definitely something we’re always working on here in my office. I don’t have a health coach in my practice, although I’ve certainly thought about bringing health coaches on, especially with there’s a new program out there designing folks just for functional medicine clinics, but I do have an amazing nutrition team. I’ve got five, I’ve got two nutritionists, and three nutrition interns, and I really lean heavily on those folks for a follow-up, and guiding people to stay on their various therapeutic diets that I’ve prescribed. Do you recommend those? I’m sure you’re recommending support staff. What kind of support staff are you recommending for clinic? Actually, you know, Dan, answer this specifically for the new doctor starting out, or transitioning in.
Dr. Dan Kalish:
For brand new doctors starting, it’s best to do the nutritional follow up yourself for a couple reasons. One is you’re trying to fill up your schedule still. You’re not booked out for two months. You want to have that extra time. The other is, it’s probably more important than that, that’s like the business perspective, the clinical part of it is that you want to create your own nutritional coaching, your own follow-up systems based on things like what IFM teaches, based on things like what I teach, and my practice management courses. You can’t just cookie cutter it.
You have to adjust it to your personality, and how you want to do things. It’s easier if you do that yourself while you’re working with patients who are paying you. You’re basically getting paid an hourly rate to develop the system that you want. Once you’ve perfected it, and that’s going to take at least three months, probably more like six months or a year for most people. Once you’ve perfected that system, then you can bring on a nutritionist and say, “Hey, here’s my system. On week two I do this. On week three I do this. Here’s the scripts. Here’s the handouts. Here’s what I want to see happen.” You have, then, some consistency in creating a patient experience that you’re trying to create. I think for those two reasons, it’s better to take that on yourself.
I did this for probably too long. I did all my nutritional coaching, oh gosh, at least for five or six years. Then, I hired a nutritionist. I set up a system where I have a little worksheet, and I’ll check off on the worksheet the things I want the nutritionist to focus on, that we’re on the same page, and the patient feels like we’re communicating, but then they go to the nutritionist for the actual work. I made that transition when I got to a point in my practice where I was just so busy that I couldn’t handle, I didn’t have time in a week to do the follow up. There was nothing on my schedule, and honestly, I was a little bored about talking about gluten. How many thousands of times can you give that talk? I gave it many of thousands of times, and I was like, “Okay. I think I can hand this off to someone else, now.”
Kara Fitzgerald:
It is important to really know the ins and outs of the therapeutic diet, and to go through that experience. I’ll tell you what. I was very excited to have the support of a nutrition team. All right. Big, big, big, big, big, big question from patients. When am I going to feel better? How do you respond?
Dr. Dan Kalish:
Let’s see. There’s a method to this. I’d say if we’re getting the lifestyle changes implemented, if they’re stopping caffeine, alcohol, tobacco, no … Let’s say they’re stopping all the alcohol and caffeine, and they’re doing a gluten free and sugar free diet for the next thirty days, you can kind of guarantee that. If they’re starting in on their supplement protocols, and I see the labs, and I can tell pretty much how well that’s going to work, then I’ll give them my standard rep.
Which is that, “You should start to feel better in three or four weeks. Eighty percent of this is going to come about because of the lifestyle changes, because you’re going to stop alcohol and caffeine, and you’ve got this amazing diet that you’re going to start following, and all these supplements. Twenty plus of this is completely reliant upon supplements, assuming you do the diet and lifestyle changes perfectly. If you cheat on the diet and lifestyle, it takes a while for you to implement it. It may be that your benefit is only fifty percent from the lifestyle, and then the supplements have to step in for that other fifty percent, and then it’s obviously going to slower.”
I want to throw it back at them, and let them know that the faster they make the lifestyle changes, the faster this is going to go. That the supplements are critical, but they can’t get away with no lifestyle change, and tons of supplements. That’s not the model. That’s, of course, what people try to do. Everybody wants to stay on the alcohol and caffeine, and just take enough supplements that they feel better. I try to set it up in that way, and then if they’re three or four weeks into the program, and they’re not feeling better, then I know either the lifestyle changes aren’t being initiated, or that I didn’t design the supplement program properly. I may need to adjust things.
That’s sort of my standard answer, but I really want to make … You and I know that, well, it was like in the study that I did with the Mayoclinic. This was the most dramatic example of this, because we had twenty five women all doing the exact same thing. In the first six weeks of the study, we hadn’t gotten the lab results back, and no one was on any supplements. I saw the most dramatic clinical changes of my career in this group of twenty plus women only with lifestyle changes. Not a single supplement of any type. That’s just reinforced the concept. We always know this, and say it, but sometimes we kind of forget. It’s really not supplement driven, what we’re doing. I try to instill that in patients as much as I can. If things aren’t going well, we problem solve about how we can improve the lifestyle factors.
I always undersell things, and I also, when we’re looking at supplement program design, I’m always looking for, “What’s the number one thing you want to have go away?” There’s always like three things that everyone says, “I don’t want to be tired anymore. I want to lose weight.” I don’t know what the other one is. Maybe, “I’m depressed, or anxious, or have low sex drive,” or something like that. I also try to target the initial supplement protocol to have a really strong symptomatic relief component. I often times target, and this is sort of, in my own mind, controversial, but I often times target the underlying cause of their problem to be dealt with in month two, or three, or four.
Let’s say their main problem is heavy metal toxicity, or their main problem is giardia. I often will hold off on that treatment for the giardia, or the heavy metals, until we’ve built up their reserve, and they’re feeling a bit better from the mitochondrial energy program, from the adrenal and thyroid program. I do try to steer the program in that first month or two towards feel good supplements that are symptomatic relieving, so that they have a sense of enthusiasm and buoyancy about the overall work that we’re doing, and then we hit treat the giardia, treat the heavy metals. As we know, oftentimes leads to people slipping back in terms of increased symptoms and side effects, things like that.
Kara Fitzgerald:
That makes total sense. I do. I mean, I work with a lot of allergy patients. If I’ve got somebody with head to toe hives, and they’re itching so profusely they can’t sleep at night, we have to deal with that first. We have to get them some sleep, be it some very high dose botanical antihistamines, or using pharmaceutical antihistamines. We simple have to do that. If we put them on an elimination diet, of course we need to do that for the underlying issue, and correct the immune imbalance and so forth, but they need to be sleeping, and ideally they’re sleeping that night. Certainly, it’s important to consider palliation.
Arguably, when we’re using functional medicine, palliation is often, has its tentacles in root cause as well. If we use botanical antihistamines, they’re going to offer some sort of balancing effect, potentially, to the immune response. I hear you. It makes total sense. I could pick your brain all day. We’ve got so much to cover, but I’m just going to ask you a couple more questions. How many supplements do you think about prescribing at the start of the program, and how long do you expect people to be on them?
Dr. Dan Kalish:
I screwed this one up for a long time. When I was learning functional medicine twenty five years ago, I watched what my teachers did, and I mimicked them. I would routinely see patients in the clinics where I was being trained on fifteen to thirty five different products taken at six, or eight times of the day, in the dozens, and dozens, and dozens, and dozens of pills category. I wasn’t really processing things. I was like, “Okay, this is functional medicine. Maybe that person had a tumor in their throat the size of a grapefruit, or maybe that person had really severe autoimmune disease.”
The guys that trained me were just so … Their practices were full of such sick people, that I learned this really extreme version of functional medicine, where there was no time to mess around, and to do anything but a full program in every sense of the word. I mimicked that for a long time, and then I look up one day, and I realize, “Wow. You know what? I don’t really have any cancer patients. These people are not that sick, and they’re all complaining about having to take so many pills, and supplements, and stuff. I wonder what the minimum amount I could do to get away with would be?”
I went on a journey for many years to try and figure that out. I ended up with the number nine. If you look at my health plans, there’s only nine slots. If I’m going to go above nine supplements, then I have to get out another sheet of paper and start thinking about why I’m even doing that. I found that the number nine, and I treat my average patients on somewhere probably between six and nine supplements, unless they’re extremely sick, in which case the number might go up, but not for very long. Then, what I try to do now, and I think the art of minimizing the number of products you give is to sequence things properly, so that you’re delivering results at each phase of the treatment, but you’re not trying to do it all at the same time.
I have a really specific way I teach that, and I do that in my own practice. I don’t think it’s important to necessarily mimic what I do, other than conceptually, so that you have a concept of program design, and you’re breaking each one of these programs, which is maybe six to nine different supplements, into the priority list that you want, and then implementing them. Then, maybe sometimes there’s some overlap between programs, but not for very long.
Now, the sicker the patient gets, the more they’re willing to take more products, but my practice now, and what I really try to encourage doctors to start with, is a lighter weight version of functional medicine. I think we should learn to do this work on easier patients, not on the really hard ones. I think it’s safer for the patient if you learn on easier patients, less likely to cause a problem. It’s easier for the doctor to get up to speed and to learn how these things work. What I find with all the great doctors that trained me had practices that attracted the sickest people in the world, literally. That’s a hard place to start.
I really suggest people, like we’re talking about niches earlier. Go for an easy niche. How about female hormone imbalances, or Hashimoto’s is a great one. Pick a niche where people are still working. They’re not in and out of the hospital all the time. Don’t have hives all over their entire body, maybe just have hives every month, so that you’re not thrown into the deep end of the pool, and trying to learn on the hardest people. That’s one thing I feel really strongly about, because it burns doctors out, and they get frustrated, they think it’s not working, because they don’t have the skills to address these really difficult patients yet. Starting on the easier side.
Most of the people in the training programs that I run, they’re working around the nine to ten supplement picture, as well. Another thing I always try to emphasize is the better we do our job, the faster the person will get off the supplements. These are supplements, not permanents, is my joke I always tell patients. Supplementary to what? To your diet, to your meditation. We’re using the supplements to boost you up enough, quickly enough, and to repair a lot of the things that were damaged, but ultimately the treatment’s going to segue over to continuation of the meditation, the exercise, the diet, most other things.
Kara Fitzgerald:
Thanks for mentioning meditation. I know you’ve got that as a component, the mind, body piece, and exercise as well. You have a full approach. We haven’t really touched on that today. We’ve been touching more nuts and bolts practice building here, but yes. We need all of them.
Dr. Dan Kalish:
I meditate at least two hours every day. Basically, I wake up at four in the morning, and I usually meditate until around seven, seven thirty. I did this morning. To me, that is the most important part of functional medicine. When I look at all the great functional medicine doctors, and you are I are about the same age, I think, or same generation. You can think about all our teachers. They all, every man and woman I can think of, primarily had a spiritual perspective on healing. They may have also been lab directors, and PhDs, and chemistry, and naturopaths, or chiropractors, or medical doctor, whatever their licensing was. They all shared a deep belief that healing is primarily a spiritual event.
As practitioners, we cannot access the most powerful tool unless we’re meditating ourselves. Forget about your patients. Getting your patients to meditate is inconsequential if you’re not doing it, right? I do feel like that’s the underlying basis of functional medicine, even though my teachers never talked about it a lot, certainly not in public, I just think it’s the subtext under which we work.
Kara Fitzgerald:
Right. That’s a great note to end on. I was just going to ask you for final words of wisdom, but I think that’s really lovely. Thank you so much for spending this hour with me. You’ve really provided such valuable information. It’s been inspiring to listen to you, and I know clinicians who check out this podcast will be well guided. We’ll put contact information on here for finding Dan, and finding his site, and a little bit more about his work. Thanks again, Dr. Kalish.
Dr. Dan Kalish:
Appreciate it very much. Thank you.