Latest / Voices of Otolaryngology / Putting Physicians in the Driver's Seat: Culture, Scale, and Physician Leadership

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Putting Physicians in the Driver's Seat: Culture, Scale, and Physician Leadership · Voices of Otolaryngology

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Welcome to the Voices of Otolaryngology podcast series, where we spotlight
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diverse perspectives and insights within the field of otolaryngology.
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I'm your host, Rahul Shah.
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Let's jump into it.
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Welcome to Voices of Otolaryngology.
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I'm so excited today.
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You know, sometimes I say some days you just get lucky.
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So I have two of my new friends here, Doctor Cooper and Doctor Vivero.
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Gentlemen, thank you for joining us.
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Thanks, Rahul, happy to be here. Thank you.
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Great to be here.
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Should we do a spoiler alert?
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I’m coming to us here from the DMV - District of Maryland and Virginia.
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It looks a little bit gray back there. Is that gray back there?
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Doctor Cooper, is it raining?
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Is it bad weather where you are?
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No. It's actually a gorgeous day here in South Florida.
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Yeah.
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Well, why don't you tell us a little bit about yourselves?
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We usually don't have two guests, but I couldn't break
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you two apart because the story's a awesome story of evolution, of practice.
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So, Doctor Cooper,
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maybe a little bit about your training, med school, where you grew up.
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And then we'll do that for Doctor Vivero.
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Then we'll go back and forth a bit. Doctor Cooper....
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Thank you.
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So first, please call me John. Jonathan.
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We’re colleagues.
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And this is gonna be a fun, fun conversation.
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I grew up in New Jersey, raised in New Jersey, North Jersey,
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educated in New York, did my training in otolaryngology in Miami.
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I have been in private practice since 1992.
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I am very happily married to former audiologist.
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We met while we were both training.
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I have two wonderful children and I'm going to brag just for a moment.
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My daughter is just finishing her internship here in otolaryngology
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in Miami, so she's going to hopefully continue the tradition.
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And I have a 30 year old son who is a software engineer.
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Yeah, I
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think you you bragged there about your daughter, but
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I really probably that's a raison d’état, for for all of us, right?
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We are here for the next generation.
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So thank you for mentioning her, because this is what we do, what we do.
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Do you agree?
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I mean, you wake up every day
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and you want to make it better for the next 20 or 30 years.
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That is a large part of what I do on a daily basis.
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And that's,
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I think part of the reason why Rich and I are here is speaking with you
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today is we are really focused on, on the future of Otolaryngology.
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Yeah. Agree completely.
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Rich, do you want to tell us a little bit
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about yourself, background, growing up, training, etc.?
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Yeah, my name is Richard Vivero.
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I am an Otolaryngologist that's born and raised in Miami, Florida,
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went to Harvard for undergrad, and then I went to University of Miami
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for med school and a short residency, and I did my fellowship at Mass General.
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Got back to Miami after residency and fellowship and joined
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South Florida ENT Associates, which became the basis of Elevate,
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and was able to grow in the business, continue to practice,
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but I've been able to also take a leasership role in the business.
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Happily married as well,
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like John have a 13 year old daughter, or soon to be 13 year old.
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So some days I'm loved, some days I'm disdained.
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But today.
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Today was a good day and I'll take that.
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It seems like a sitcom.
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I was there when you and I both said the same thing.
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Teenage children are not easy.
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So you.
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You were in Boston, Miami, Boston, Miami, a little bit back and forth there.
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And what was the fellow in?
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It was in Otolaryngology at Mass General with Steve Zeitels.
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So Patriots or Dolphins?
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Oh, man. If I want to win, I'd say Patriots.
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But growing up here, it's Dolphins.
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As painful as it is, man.
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We can't get past the first round of the playoffs.
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When I grew up in the Washington, D.C.
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area, but I still grew up with Dan Marino, right?
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We all loved him there.
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Jonathan, I was struck.
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Thank you.
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When I visited, you all invited me.
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It was an amazing visit. I learned so much.
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Thank you for transparency.
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Literally showing me everything.
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I was most struck.
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First, you picked me up at the airport, which I very much appreciate.
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But you told me a fascinating story of how your practice evolved.
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Can you summarize that in like 75 seconds?
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I know it was like a 20 minute discussion, but you literally it's an amazing story.
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You came out of residency and where you are today.
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I mean, it's just and focus on the early part
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because a lot of trainees listen to this and we think, you know,
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I joined this practice and and I'm cemented in there, John.
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Sure.
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So when I was a chief resident, I wanted to go into private practice
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with one of my co residents.
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So we were recruited by a local hospital who didn't have ENT coverage,
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just a little bit north of Miami
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and they guaranteed it then income guarantee to start a practice.
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And that was the beginning of learning how to run a business.
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Because I had no idea how to find an office, equip
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an office, credentials, an insurance plan, all that kind of stuff.
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So we did that together.
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He left after about a year and a half to take a job as an employee
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physician in at a hospital in North Carolina,
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because we were not making a whole lot of money.
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And it was a bit of a slog.
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But I became what I felt was successful
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over a period of 7 or 8 years, being by myself.
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It was a bit of a challenge on call every night.
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Every weekend, I had to speak to local colleagues and other
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small practices to get coverage if I wanted to go on vacation.
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And as that was happening, just around 1999-2000,
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one of our major insurance plans
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in Florida sent a letter to every otolarangologist in Florida
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telling us that our new contract rate was going to be 65% of Medicare.
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And this was devastating
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to someone who was by themselves and had no resources, etc, etc.
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And through the wisdom of my mentor in business, Frank Kronberg,
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who's a practicing otolarangologist in South Miami,
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he got a bunch of us together for a meeting and said,
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we need to do something about this and we need to work together.
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Otherwise we are going to never be able to succeed in business.
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And he was successful in combining 13 practices together.
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25 physicians into was then South Florida ENT Associates.
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And we began the process of
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negotiating with
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insurance companies and purchasing together and grew a very successful
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group practice in the Southeast Miami area.
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And that was really very, very successful.
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And part of what we find ourselves on was sort of, look, in five, ten years
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in the future and what's happening around that time, around 2015, 2017,
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a lot of the hospitals started to hire otolarangologists.
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Hospitals started to form clinically integrated networks, accountable
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care organizations and things that were really primarily
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focused on shifting what we felt, shifting resources to primary care
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and sort of minimizing the effect of specialists and surgical specialists.
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And that's when we, as a board
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of our company, decided that we would look to what the next step is.
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We wanted to grow bigger.
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We were very successful in our environment in Miami-Dade and Broward counties.
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We wanted to grow
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throughout the state of Florida, and then we started to look for how to do that.
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And after much discussion, we decided a partner was probably the best way
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to do that, to help give us a solid financial backing.
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Pause just to second.
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Because I want to I don't want to rush that part of the story.
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That was perfect.
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I just loved the part.
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And it it gives me chills every time I hear it.
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You and a residency classmate said, let's go hang up a shingle.
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Yeah,
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we we got along very well through your five years of training.
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You know, back in the day, we didn't have time
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limits on how long we could be in the hospital.
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So we spent a lot of time with each other.
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So we figured if we could survive that together, we could get each other through,
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you know, marriage, children and all that kind of stuff.
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And my goal was just to be a, you know, a community otolarangologist,
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taking care of anybody who walked in the office.
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I never thought I would be sitting with the CEO of the Academy,
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having a conversation at any point in my life.
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But, you know, circumstances change and you have to be willing to adapt to
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what's going on around you, and you have to be real active, I believe,
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to position yourself to be successful and to remain successful.
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Yeah.
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I mean, right there, we could we could end right there, Rich.
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And I bet you there's a lot of pearls in those couple of minutes there about
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how you have to stay ahead of where the game is.
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It's fun to have two experts here, John and Rich.
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So Rich, I'm going to have you kind of describe the present day.
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And then John is going to bring us back.
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Okay. That's the theme of the day.
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He's going to start and then and move us forward.
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Doctor Vivero, what is Elevate?
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When did you enter the picture and tell us about your thought process
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coming out of fellowship training, wanting to come back to Miami?
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What was going through your mind
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and then bring us a little bit up to modern day Elevate.
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And then I'm going to bring John to bring us on that trajectory.
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Yeah, absolutely.
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Thanks, Rahul.
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So I mean, I joined straight
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out of fellowship at South Florida ENT was the preeminent group in South Florida.
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And I've thought that there would be value add
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by having vertically horizontal integrated.
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So we could have sub specialists provide advanced services.
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I was quickly rose to the ranks and became part of the board of South Florida ENT,
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and then was part of the team that led to the partnership that John alluded to.
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Elevate ENT is a management services organization.
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It's a service provider for practices.
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And we're currently in four states.
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We're in Florida, Texas, Louisiana and Tennessee.
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And we partner with practices in a lock their equity value.
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But we also provide a bevy of services so they can run their entire back office.
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And the way our CEO described it is that we are the pit team for an F1 racer.
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We want to keep the doctors out there doing what they do
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best, by taking off their shoulders all the business needs that
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come along with this: compliance, payer contracting, IT, HR, etc.
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In so doing, we've been able to grow from 50 providers now to 173 providers,
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physicians, over 300 clinical providers,
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and over 1700 employees in this process.
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And what we pride ourselves on is delivering high quality care,
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unlocking the full range of services that ENTs can provide,
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whether it's allergy, audiology, imaging, etc.
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and looking at the future of how we can continue to preserve
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a semblance of prior practice when there's a lot of headwinds in medicine overall.
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We are now in 2026, Doctor Cooper mentioned.
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I think it was over the late 1990s. 2000.
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When did you join Rich?
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I joined in 2013. Two
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yeah. 13 years ago.
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And help, help our our listeners understand,
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because a lot of them are early training young physicians.
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So you joined you joined Doctor Cooper's practice at that time?
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It was actually I mean, we were and we were one big partnership.
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I joined, actually Frank Kromberg’s practice, our original founders.
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I'm in Miami-Dade County, Johns just north of me and Broward County,
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but we are all partners.
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I was just in the different physical office.
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And then when you joined, coming out of fellowship training,
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were you able to say, look, folks, I want to do 30-40% larangology,
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or get us through that mindset?
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Because when people leave fellowships, sometimes they are in that way of
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thinking.
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What were you thinking coming back to join the group?
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I mean, starting in private practice, I realized I had to do all facets of ENT
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to start, and I had to slowly craft my practice and grow it.
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So I started off
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doing a little bit of everything, and then my partners
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would start sending me larangology cases. And as my reputation
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grew in the community, my referral patterns aligned with that.
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So now my practice is probably it's basically 100% surgically larangology.
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And then
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clinic-wise probably 80% larangology -
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which is exactly where I want it to be.
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And it gives me a great opportunity to take care of all facets of my patients
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here. Yeah.
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Thank you, Doctor Cooper.
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Let's let's go back maybe 20 years or so
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and I rushed you through it.
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I apologize, but it's it's just a fun story.
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So you come together, and it must have been a shock when you saw 65% of Medicare.
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And you're like, how could I?
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How could I do this?
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And then what was going through your mind?
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And you use some really astute words.
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About five minutes ago, we had to be proactive.
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We had to evolve.
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And when I go around the country, the practices that are succeeding
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have that mindset.
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John, talk a little bit about that.
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Now we're going in the early 2000.
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Yeah.
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So everybody was concerned because there is no way we could float
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our practices on 65% of Medicare if every other insurance company followed suit.
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So we also were always told that we could not work together.
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We couldn't negotiate together.
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The chips are sort of stacked against you and little isolated practices.
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So we had to get some legal counsel
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and we had to find out legally how can we address this.
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And it became evident that the only way that we could really address
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it was to truly become one practice, one Tax ID number, one accounting system,
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one accounts
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payable system, all the legal requirements that the government would have.
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Because we also felt that once we started to negotiate and to sort of
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try and impose our will on people,
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we would become a target for an antitrust action.
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So we had to do things by the book.
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So we engaged counsel.
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We structured a a partnership
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that was based on equity, equality for all of our partners.
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There's no way
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we could have gotten everybody together if there were different tiers of
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partnership.
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So everybody from the beginning was equal.
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And we decided as a group
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that we were going to tell the insurance company, if the one that was
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we felt attacking it, that we were not going to accept that,
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and they could either
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pay us a reasonable amount the money or we would not take care of their patients.
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And it was a very nerve wracking moment when we signed a letter
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to resign from the insurance company when we sit in our boardroom, we're like,
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are we really going to do that?
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How many people were around that table?
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When you signed that letter?
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Well, there were 13 practices and on the board it was a little bit
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bloated at the time.
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We had 11 people because everybody wants to know what's
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going on and have a voice - But 13 practices.
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So you are making it sound easy, but it is hard.
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So how did you get from one practice,
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a solo practice to bring 13 people around the table?
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Physicians, by definition, are autonomous and solo.
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How did you get them all to say, let's
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join hands together and let's do a trust fall?
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That's essentially what you orchestrated.
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It was really forced on us from outside influences - the insurance company.
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You know, we all
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individually decided we could
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not survive at 65% of Medicare and what we're going to do about it.
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And then we looked at what are our options?
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Then the only legal way that we could address
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this was to form a group practice.
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And we
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we we did our best to make sure that everybody's individual interests were
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sort of maintained so that if you wanted to stay in your office,
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stay in your office,
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if you want to have for MAs and a scribe, you could have four MAs and a scribe.
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We didn't want to become a cookie cutter, one way to do things type of practice.
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And that is what - that philosophy
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has continued on through today through Elevate.
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John, I could see Rich.
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I haven't forgotten about you, but I could go all day on this because it
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you know, I spent almost 36 hours with you and I wouldn't stop talking.
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So, John, a decision like this could take 18 months to two years.
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But you all had to act fast, because if they were at 65% Medicare,
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you had to get the groups together. You had to get a letter.
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How long did it take? About six months?
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Nine months? It took a it took about a year.
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It took us nine months to to craft and agree on our documents about how
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we were going to be put together, what everybody's rights/responsibilities were.
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And we we, the physicians took a very active part in that.
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We took some boilerplate sort of standard employment agreement and document
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and made them our own, and then sent them to attorneys.
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We didn't want to attorneys telling us how to do it.
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So from the beginning, we crafted our agreements.
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That process took nine months.
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As soon as we had all the legal stuff.
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You know, I’s dotted, T'’s crossed.
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We one of our first meetings was, okay, let's do this.
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Let's, you know, announce our presence by telling this insurance company
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that we are not going to play ball this way.
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I love it.
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We always think of catchy titles and themes for our episodes.
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I think I've figured it out.
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I mean, you wanted
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to put the doctor in the driver's seat if we're continuing the F1.
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I mean, that's awesome. John.
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Yeah, that is absolutely the philosophy that we've had is, you know,
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I look at it more like a bus because there's a lot of us,
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it's hard to get more than one person in F1 car,
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but you can be in the back of the bus going wherever the hell the bus goes.
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Or you can be in the driver's seat directing where it goes,
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or you can be the navigator with your hand on the wheel, guiding it toward
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where you think it should go in partnership with everybody else.
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So then, Rich, let's let's go to 2013.
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How many doctors/providers were they when you joined in 2013?
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And did you ever think you'd have 173?
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You'd have a Net Promoter score of 90.
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I want everybody to hear that Net Promoter score of 90.
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I walked into those offices, Rich, you and I started laughing.
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They were staff older.
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Wait, wait. No no, no.
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There were staff that had been there older than we are, if that makes sense.
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So we're in our 50s.
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You've had staff there 45, 50 years.
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It was crazy. Yeah. So talk about that.
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And you know what you were thinking when you joined in 2013.
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Yeah I mean, I think we've been very fortunate.
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We started off with about 50 providers in 2013, and now we've scaled to 170.
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And I don't think at that time
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you could envision us growing as quickly and as largely as we have.
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It's a testament to the fact that we create something that's durable.
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I think this goes back to what
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John and Frank Kromberg started 25 years ago with a vision of.
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And John says all the time, we don't make money off our partners.
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We grow together with our partners.
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And by putting together a team that put patients first
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and preserving our practice, we're able to continue to go around that.
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So to that point, we've had that longevity with our employees,
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because we also try to put our employees at the top of that totem pole,
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because it's a place we were trying to build a culture
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where it's as a family that that that grows together.
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And it's not easy to do, like families, there's little spats,
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but in the end, we're always we're trying to row in the same direction.
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And that's been really meaningful.
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Yeah, I was really struck.
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The most prominent part of your two story office building is the culture wall.
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It's pretty impressive.
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I don't know, maybe 40ft by 20ft.
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By the way, we copied that here at the Academy.
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So that's you inspired us.
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No, I'm serious.
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And I, you know, people talk culture, but everywhere I saw, they kind of live
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that and breathe that.
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Rich, how did you imbue that as a physician leader over the last 13 years?
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And how do you how does that keep you awake at night?
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And does the culture really matter when you're at 173 docs?
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Well, I dare say culture is the most important thing.
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I mean, it's the glue that ties us together.
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Coming from Miami and Miami Heat fan - Miami Heat fan is defined by culture,
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and I think that's something we try to bring together with Elevate ENT.
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And I think the first thing you need to do for culture is model that culture
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of leadership, guidance, empathy, respect and support.
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And I think John and I and the rest of the team
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try to do that with all of our employees, with each other.
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And it's it's really, really critical.
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I dare say, as we get bigger, maintaining
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that culture is going to be critical to our future success.
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Perfect segue to your partner, senior thought leader John.
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We don't know what you call you.
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Maybe you're not the pit boss.
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You're probably the team principal.
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And rich.
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Rich, there might be the driver and I'm just a commentator.
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I'm the guy who walks around with the mic.
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So, John, let's talk both of you
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a little bit about scale, because not all scale is good.
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And you had 13 practices early 2000’s.
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173 now.
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2013 you had 50.
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John get it, get us in your mind there.
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And the other doctors, when you think about scale, when you think
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about bringing other states on?
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Folks, I would have stopped at Florida.
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But you said, let's see what's going on in Louisiana?
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Let's see what's in Texas? And I know you're in another state.
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John, can you talk about scale and then Doctor Vivero, talk about scale?
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Sure. I mean, you're very correct.
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Not not all scale is good scale.
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Scale has to provide value, and it's difficult to
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write on paper
20:48
and to show someone what the value is of scale sometimes.
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And what we found was that that's what to do.
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That was to put in action, to take smaller areas, to start to build,
21:00
even within our own company, to start with certain centered
21:03
and then build out from there and show the results.
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Show that by centralizing scheduling, by centralizing
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RCM processes, by sharing employees, by sharing protocols,
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becoming more efficient, that efficiency
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eventually turns into a value.
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It's not a direct line there.
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It's a little sort of roundabout way to get there,
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but you have to.
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Physicians are critical thinkers.
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We're trained to read a journal article and look at - is this valid?
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What are the issues with this?
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So when a proposition is placed in front of the physician,
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you have to really have a solid reason for doing it.
21:43
And you have to have the data to back it up that it works,
21:47
and that there is this value that comes out of it on the other end.
21:50
By combining things together and by providing
21:53
that value, it goes back to unlocking the the real value
21:58
of the medical practice, which traditionally has been undervalued.
22:01
You know, people don't take advantage of that.
22:04
We all want
22:04
to have our own little sort of world that we live in, and we want to do things
22:08
the way we want to do things.
22:09
And sometimes you don't know how other people are doing things.
22:12
And that's another thing that we bring to our to
22:15
the table is we bring benchmarking. We show people how they're doing.
22:18
We have financial transparency with everybody.
22:20
We want people to understand where they sit in the grand scheme
22:24
of ENT practices, and no two practices are the same.
22:28
It's the other hard part about scaling an ENT
22:30
practice is - there's such variability, which is what made most of us all
22:34
in love with otolarangologiy to begin with.
22:36
Is that: Not everybody is going to be doing the same thing all the time.
22:40
So you have to scale, but in the real world.
22:44
And the best way to do that is to come up with an idea,
22:49
find people who are willing to trial it, and then proved by success.
22:54
And if it's not successful, tweak it.
22:55
And you have to be willing to tweak it.
22:57
You can't just go in saying, this is the way I want to do it,
22:59
you're going to do it.
23:00
We learn from every practice that we partner with.
23:03
There are things that are
23:04
being done in Louisiana that are better than being done in Miami.
23:08
And we take that as, you know, a better way to do things.
23:12
Very interesting. Rich, I want you to riff.
23:15
If we're a band now, I live in a world of mixed metaphors.
23:18
So now we're no longer a pit crew, but we're a band.
23:20
I want you to riff on that point about scale.
23:24
Yeah.
23:24
Heretofore I was in the misconception that scale would just be numbers. But.
23:29
But you're talking about more of scaling the culture.
23:31
You used shared protocols, you used KPIs, Sorry to interrupt you there, Rich.
23:36
it's a great point and I think I look at similarly to John,
23:38
but it's also different. I think it's a dyad.
23:40
Obviously there's scale from economies of scale.
23:41
Transparency, which allows you to get lower costs, allows you to improve
23:46
the clinical best and business
23:48
best practices that are employed in all of our offices.
23:50
And that allows us to write things together.
23:52
But you really have to pair that with the right culture.
23:54
If you bring the wrong people into the family,
23:56
then you're unable to really grow that vision, that culture, that transparency.
24:02
I mean, we really have to be rowing.
24:03
And we do say this very plainly.
24:05
We are looking for true partners, and we do.
24:08
We look at a lot of businesses that want to join us,
24:09
and not all of them are a great fit for us.
24:11
And sometimes we have to say no
24:12
because it's not part of our bigger vision of what we're building.
24:15
Not because anything wrong with those businesses,
24:17
but they're just not part of our vision, and our culture.
24:20
And so it's challenging, but we try to bring the best of what
24:22
we have to everyone that we can partner with.
24:25
Yeah.
24:26
And when you think about growing scale, you mentioned protocols.
24:32
Could you give our listeners an example?
24:33
I found that incredibly insightful
24:36
that you're sharing quality performance protocols.
24:41
Just just give a random example.
24:42
It doesn't have to be eruadite.
24:44
Give us an example.
24:46
Simple ones like hearing loss. Right.
24:47
Like the American Academy of Audiology recommends that people above 50
24:50
be screened for hearing loss.
24:51
That’s something we don't think about very often.
24:53
And that allows us to identify hearing loss earlier than it would be otherwise.
24:56
We can then get them connected with amplification,
24:59
stave off to dementia and other concerns that happen with long term hearing loss.
25:02
I mean, that's probably one of the simplest ones.
25:04
So then you can do the same thing with allergy,
25:05
and then just implementing all the clinical best practices
25:08
that come out of the Academy on an annual basis.
25:11
We're slowly integrating those into our EMR.
25:13
We're trying to employ AI to help a guide what we're doing with these things.
25:17
So it's really important that we continue
25:21
to look and see where we can standardize and optimize.
25:24
They’re
25:25
similar but distinct at the same time, because that leads to better patient care,
25:29
and I think lately, a better physician experience.
25:32
Yeah.
25:32
Well said. Well said. John.
25:34
You mentioned “metric driven.” I was absolutely astonished.
25:40
I'm a KPI guy.
25:41
I love metrics, but it's important you don't drown in metrics.
25:45
You can't have 100 metrics or key performance indicators.
25:48
John, can you talk a little bit about metrics where that started?
25:52
Have you always been a metrics person?
25:54
And then Rich, if you could talk about some of your current day metrics,
25:57
if you don't give us the numbers,
25:58
but what do you all look at as performance indicators?
26:01
I was, you know, by yourself in a single practice certainly had no metrics.
26:05
I just was trying to get through the day so that that didn't happen.
26:09
When we were South Florida ENT, we ran as lean as possible
26:15
with our leadership team, and we really focused
26:19
not on metrics and scale and things like that, but also just
26:24
negotiating insurance contracts and stuff like that took most of our time.
26:27
So we didn't have a lot of KPIs and other metrics that we were benchmarked with.
26:31
Our partnership really opened up that world to us because we partnered with
26:36
a company that had a lot of experience in medicine in different specialties,
26:41
and it's one of the reasons we did it was to not have to reinvent the wheel,
26:46
but to sort of take what they had experienced and make it better.
26:50
So they introduced us to different ways that we could look
26:54
at the practice, and it was eye opening, to be honest.
26:58
We felt we had a very good, well-run, efficient practice.
27:01
And, you know, last year, I think in my center,
27:07
I cut about half a million dollars of expenses
27:10
just by looking at staffing ratios and productivity
27:14
and different things that I really didn't have a handle on before.
27:18
So it's been a huge value both financially
27:22
and also just understanding how to make my practice better.
27:27
You yourself found a
27:28
half million of potential opportunity
27:31
cost, even in your own practice after three decades of practicing?
27:35
I'm I'm not criticizing you, but that introspection is laudable.
27:39
You get caught up in the way you do things, the way you do things, and it's
27:42
hard to see outside your lane when you don't know there's other lanes around you.
27:46
And by being shown insight into the other practices that have joined us
27:51
and from the experience of our leadership team,
27:54
it was very clear to me that there were ways that
27:57
I could become more efficient and my practice could become better,
28:01
and that's really one of the values of scale that we're talking about
28:05
earlier, is you get insight into how to do things a little bit differently,
28:09
and it takes someone who's willing to be introspective a little bit.
28:13
Not all physicians are willing to to do that, but
28:17
my goal has always been to be is the best I can be - however you define best.
28:23
So I'm looking for best practices.
28:24
I'm looking for a way to do things more efficiently.
28:27
I'm looking for ways to help my employees be efficient in their day so they're
28:31
not wasting their time.
28:34
Yeah, I mean, go one step further than what John saying.
28:36
I think oftentimes as practitioners.
28:38
And we felt I think victim to this in the past.
28:40
We're so busy looking down and dealing with today.
28:42
We're not looking forward and what's coming tomorrow.
28:45
And by having a well built out administrative back office
28:49
with people who are subject experts in all the different areas,
28:52
they're looking at these things while we're working
28:55
and they can bring to our attention areas where there's opportunity.
28:59
One quick example we can provide from one of our partners in one state.
29:03
We realized they had scheduling issues.
29:04
They had a massive no show rate.
29:06
They were working hard, but they weren't working efficiently.
29:08
By helping them just change how they scheduled patients,
29:11
understand how their schedules work looking forward, and that they could
29:15
actually predict what their no short rate was, what they wanted to see.
29:18
It's like, tell me how many patients you want to see?
29:19
Let me help you get there.
29:21
We were able to increase their productivity 40%, and they did exactly
29:24
what they wanted to do, and they weren't running in place anymore.
29:27
And that wasn't because they had time to take that step forward.
29:30
We provided them the information and that helped.
29:32
That's something, even at South Florida ENT,
29:34
we thought we were a very advanced practice with 52 doctors,
29:37
but we realized that we did not have the introspective ability,
29:42
the analytical ability to really look under the hood.
29:44
And as we got bigger and more advanced, we were able to bring those
29:47
analytical skills, those KPIs, as John and you brought up, Rahul.
29:50
So we can really understand, if we benchmark,
29:52
there are things we can do better
29:53
by just and do the same work we want to do every day.
29:57
Yeah, wonderful tangible example.
30:01
It's almost and I don't use any words disparagingly,
30:04
but it's almost like you have a management consultancy
30:07
right there to help a practice, whether it's a one practice or five,
30:11
because to get that kind of engagement is a six figure engagement.
30:15
And so that's that's amazing.
30:17
Rich, that was a perfect example.
30:19
I think you both mentioned symmetric staffing ratios.
30:22
No show rate.
30:23
Just just rattle off a few metrics that you're currently looking at.
30:26
Maybe it's your last board meeting.
30:28
I'm going to invite anyone to visit you both.
30:30
Okay. Because you're so kind.
30:33
You mean you hosted me, but you also showed us everything.
30:36
I mean, you showed me your KPIs.
30:38
Just rattle some off. What? What are you looking at?
30:40
Year over year growth, I think is always a base metric.
30:44
No show rates.
30:45
So we have some predictive analytics of where we are going forward.
30:48
Looking at percentage of people that do allergy testing.
30:50
How many people are we able actually to fit with hearing aids, understanding
30:53
that a certain percentage of all of our audiogram should lead to a hearing loss?
30:57
I think those are some of the growth metrics, like there's a quality metrics,
31:00
like we do comparisons of what our costs are relative to hospital systems
31:04
and other providers in the market.
31:05
Understanding, we're trying to provide
31:06
high quality care at a lower cost, which benefits both the consumer,
31:10
the insurance provider and the community at large.
31:13
So we were trying to feed both sides of this,
31:15
understanding that growth isn't the only thing that drives the business
31:17
- it’s got to be growth matched with good quality.
31:20
Yeah, thank thank you for that.
31:21
You can go to your website, your office website.
31:24
I was also struck by the absolute price transparency.
31:27
So if I was a small business or a large business owner,
31:30
I might look really critically to decide, do I want to send them to
31:34
you all versus another care setting?
31:38
John, give me some nos.
31:42
I'm going to talk for a second so you can think about it.
31:44
These are one of my curveballs.
31:46
Things you said no to.
31:48
And I will help you.
31:50
And if I'm wrong, I apologize.
31:52
But I think you've said no to real estate.
31:55
You will let people own their own.
31:57
Do it on their own.
31:58
I think that's right, John.
31:59
But you all made some decisions along the way.
32:03
No, we're not going to do this that have set you up for the success.
32:06
Does that make sense?
32:07
Throw out some of those “nos”.
32:09
What have you said “no” to Doctor Cooper?
32:12
We say
32:13
no to things that sort of undermine ourselves.
32:17
Sometimes people have ideas that they think are good and we don't want
32:21
we don't want our doctors competing against each other for one.
32:25
So we have a centralized, we have the marketing team,
32:30
and they're in charge of doing the marketing.
32:34
And that was a big ballot at the beginning because we all had our own websites.
32:38
We all had our own way of doing things, but we can't cannibalize ourselves
32:43
that way.
32:43
And, you know,
32:44
someone might want to have
32:45
open up a new office, but it's a mile from one of our established places,
32:49
and we're going to say you can share space with them
32:53
if their time available, much more, much more cost effective to do that.
32:57
But you're not going to compete with them.
32:59
You know, it's really as time has gone on, we have to say no less,
33:04
because people start to feel like
33:05
they're part of a large group and they really have value in that.
33:09
A lot of the nodes are breaking down the,
33:13
you know, 20, 30 years for some people of practicing by themselves
33:16
and being the captain of their own ship and doing what they want, when they want.
33:19
And, you know, sometimes you have to wait
33:22
in line to have access to marketing or to
33:28
some other person or some other activity because there's a more global
33:32
thing going on.
33:33
You know, we try and follow better hearing month and things like that.
33:38
And with the the Academy does and we put our resources
33:42
to where the sort of best bang for the buck is, I guess.
33:46
So sometimes you have to say no to our partners, but it's no with.
33:50
But we're going to help you in some other way.
33:52
We're going to find a way to take what you want and
33:56
accomplish the goal that you have, probably more efficiently.
34:00
Wonderful. Wonderful answer.
34:02
Rich, did you want to add to that?
34:03
And I've got a couple more questions.
34:05
I'm very cognizant of the time.
34:07
You've given me eight in the morning and you all,
34:09
I guarantee you have to be in the office.
34:11
But just a couple more questions, Rich.
34:12
Anything you want to think about strategically.
34:15
Also saying, no, we're not going to do AI scribes right now.
34:20
We are not going to do this right now.
34:22
I just made those up.
34:24
Yeah.
34:24
No, I mean, I think from a from a business partnership
34:26
perspective, things we've said no to, we don't we don't start ASCs.
34:29
We have our doctors invest in their own asks.
34:31
We don't buy their property. They own their own property.
34:33
Oftentimes they’re the owner/landlord for where we have offices.
34:36
We really our vision is really growing an ENT practice.
34:39
That's our main focus.
34:40
And we let people have their ancillary businesses, ancillary income streams.
34:43
Now as far as technology and growth, we're open and ready for business.
34:47
I mean, if AI scribes are where things are out, we're looking at that.
34:50
We are saying, yes, looking at AI call centers, we're looking at AI for our RCM.
34:54
We're trying to employ technologies
34:55
where they can leverage and improve our efficiency in the quality
34:59
for our both our patients and our and our physicians.
35:02
But we really want to focus on patient care, which is core and everything else
35:06
that's not core to that.
35:07
We leave for our own doctors.
35:09
Yeah, very, very well said.
35:12
You all have deftly seen where the puck is going over the last three decades.
35:18
Spend a couple minutes helping us
35:22
and our community think about where's the puck going.
35:26
Let's start with John and then Rich John three, five years.
35:29
Are you even looking ten years?
35:31
I'm not man. I'm looking 3 to 5 years.
35:33
But where are you looking?
35:34
Where's your horizon? Where where are we going?
35:37
We're looking, I think at 3 to 5 years now.
35:40
One, I think truth in the world is that things get faster
35:43
and fastern as time goes on.
35:44
And right now, AI is really going
35:48
to change the world, including in medicine.
35:51
And there's so many platforms out there and so many things to do with AI
35:57
and trying to pick the right one and who to partner with and how to invest in it.
36:02
That is a lot of what we're trying to do right now,
36:05
and certain companies are using AI against us.
36:08
We are starting to use AI to combat their AI.
36:12
And you know where this winds up?
36:13
I don't know.
36:15
And the I think the technology advances, like
36:20
AI are really what's going to define how medicine is practiced in the
36:24
next few years, but nobody really knows where it's going to shake out.
36:27
Nobody knows who's going to survive all the consolidation. It's going to happen.
36:30
Or, you know, lots and lots of startups and great ideas.
36:34
And like anything else, it's going to consolidate eventually.
36:37
But I think it's going to be accelerated compared to things in the past.
36:40
It took a long time for EMR systems to consolidate down to 3 or 4 viable
36:45
options,
36:46
and I think AI is going to make a lot of stuff happen much faster than that.
36:49
So because we have an IT team and because we have an implementation
36:54
integration team, and because we have a finance team, we're able to have
36:58
people keep an eye on that while we practice medicine.
37:01
We don't have to go home at 6:00 at night and worry about what
37:05
AI is coming down to take our jobs away.
37:08
So, Rich, I'll get to you.
37:10
But this will be our third final mixed metaphor.
37:12
We were an F1 team. We were a band.
37:14
Now we're sitting at the poker table, all three of us.
37:17
It looks like, John, what you're saying is you're not going to follow
37:22
Rich and Rahul going all in.
37:23
You're just kind of watching and thinking a little bit.
37:27
But when you do need to push all those chips
37:30
and you might have to do quickly. Did I get you right, John?
37:32
Is that what you're kind of.
37:33
You're just watching a little bit?
37:35
We are.
37:36
We're watching the learning and educating ourselves
37:39
so that we can make the best decision that we can make.
37:42
You have to be careful, I think, in this time in history about
37:46
going all in too early on,
37:49
technology that really hasn't proven itself yet.
37:52
So we're trying to sort of spread ourselves out a little bit
37:56
to keep our finger in the pot, as it were, but not commit to that all in just yet.
38:02
And I do love to play poker.
38:03
So I do think that at some point
38:08
it will consolidate and we will find an AI partner.
38:11
And AI will, by definition, it'll teach it and it will become greater
38:15
and greater as time goes on.
38:16
And we might make a mistake, but we're going to try
38:18
and make an informed mistake if we make a mistake.
38:22
Rich, I want you to go on that.
38:23
But I'll tell you, John, I am never playing poker against you.
38:26
You, like, live in a poker face.
38:28
Your whole face is a poker face.
38:30
I can't, I can't read you.
38:31
It reminds me of a casino in Montreal I went to - it has a blackjack table.
38:36
I don't know if you've ever seen this.
38:37
You could bet behind the person.
38:39
So if I'm ever with you, I'm going to just bet behind you, John.
38:42
Whatever you bet, I'm going to bet.
38:43
I'm never doing a table with you, man.
38:46
It's a great way to lose your money.
38:47
But thank you.
38:50
Rich, build on that a little bit.
38:51
What is your horizon?
38:53
What do you think?
38:54
And for the next, whatever that horizon is. Yeah.
38:56
I mean, I think 3 to 5 years I think is a healthy part.
38:59
I mean, there's a couple of good books out there.
39:01
I mean, you always have plans 70% for one year, 20% for year two,
39:04
10% per year three.
39:05
As for how you allocate your time from a planning perspective.
39:08
So I think 3 to 5 makes sense.
39:11
To John’s point, I think AI is always top of mind.
39:12
It is changing so rapidly, and it's has its fingers
39:14
in many parts of our business, and we have to be cognizant of that,
39:17
and we definitely can't ignore it
39:18
if we want to continue to advance and deal with the upcoming headwinds.
39:22
Some areas I think they're interesting
39:24
that we need to look at is when you look at ENT as a as a practice
39:27
and as a business, there's a degree of inelasticity.
39:29
Doctors can only do so much by their own hands.
39:31
So you can only scale so much.
39:33
You can't see more than X number of patients per day.
39:35
You can't do more than a certain number of surgeries per day.
39:37
So how do you scale your practice without working harder?
39:39
You have to work more efficiently.
39:41
So do you bring in additional revenue lines, like otology, audiology?
39:43
Do you bring in biologics? Do you bring in imaging?
39:45
Do you leverage sleep?
39:46
And looking at all those different verticals, how we can be a more
39:49
encompassing, well-rounded business?
39:52
And the third thing
39:53
I think looking forward is we're going to have issues from a
39:56
staffing perspective, providing providers with the number of people
40:00
in the community.
40:01
We're really graduating a pretty steady - Yes,
40:04
we've increased the number of residency spots over last few years,
40:06
but it's going to take years before those doctors make it into the community.
40:09
And in that time, there's going to be a gap.
40:10
We're going to have doctors retiring, and we have a larger
40:13
number of people who need care.
40:15
And a lot of our community, especially secondary markets.
40:17
It's hard to recruit MDS to move out to smaller communities.
40:21
So how do you get people out there?
40:23
What kind of package do you get them out there?
40:24
Because those people need care too.
40:26
And looking at that, how do we leverage apps
40:29
to make the doctors really extenders and not replacements for physicians?
40:33
And that's a real challenge because it puts us at risk.
40:37
Clearly we don't want audiologists and APPs taking over our business,
40:41
but we do need people to provide care in communities.
40:43
How do we work together to to provide them a seamless fashion?
40:47
Yeah. Awesome.
40:48
Now everybody knows why I love listening to you both.
40:50
I get smarter even in the last 35 minutes.
40:53
A couple more questions, I promise.
40:55
I keep saying that I think three more, I promise.
40:57
One, either of you just right off quickly if you can.
41:01
Best of your knowledge, what AI tools
41:04
does Elevate as a professional services/managed services
41:08
organization or your specific practice employee today or imminently?
41:13
What AI tools?
41:15
I mean AI call center is in process to facilitate that.
41:19
And that would be paired with human beings as well as a as a back end to improve
41:23
accessibility after hours and weekend connections and to streamline efficiency.
41:29
Second one is AI for RCM: revenue cycle management.
41:32
As all of us are well aware in ENT,
41:34
there's a lot of automatic downcoding happening.
41:36
Thanks, Rahul, and team for handling that at the Academy level.
41:39
That was a great work, but clearly it's happening in multiple markets.
41:43
There are a lot of payers.
41:44
South Florida has a tremendous number,
41:45
but we have them in every state that we're in.
41:47
How do we stay on top of that?
41:49
And it's just so much data and basically it's a question of attrition.
41:52
Who's going to give up first.
41:53
And by having AI allows us to leverage that.
41:55
So we have an issue I think.
41:57
And third, but not least is how do we use AI for for documentation?
42:01
I think we can all agree as physicians documentation,
42:03
usually the bane of our existence and how we leverage AI
42:06
in our in our EMR system, we have an AI functionality
42:09
that's been rolled out, and it's, I think, scaling nicely.
42:13
But I would agree.
42:14
I think those are top three we're working on right now.
42:16
Hopefully have them implemented within 26.
42:19
John, anything to add to that? I thought that was thorough.
42:21
I just wanted our members to know what you all are thinking about.
42:24
Yeah, that's really our area of focus right now are those three things.
42:27
And you know, two of them are really sort of behind the scenes.
42:29
And one of them is the physician interface.
42:31
So physicians are very anxious for AI to have to
42:37
to get them to stop clicking and account click doctor click.
42:41
But it's not quite there yet.
42:43
But it's getting better every every year.
42:46
But I would the plug evidence.
42:49
So when you recommended the Academy last year, that program is spectacular.
42:52
And the partnership with the the Academy is great.
42:55
Open Evidence, as you guys
42:56
know, is for primary literature to task questions really really helpful.
43:00
Yeah, terrific. I agree as well.
43:02
Now we're down to two questions.
43:03
I promise you,
43:04
the Academy launched something called a Physician Leadership Institute.
43:08
And there are 20 seats.
43:10
I was blown away that you all took two of those seats,
43:14
meaning you paid the money and made the investment.
43:17
And John first, and maybe Rich.
43:20
Physician-leaders has always been core,
43:24
from what I've learned, to you and the practices that you've evolved in.
43:28
Why physician-leaders?
43:30
You obviously are investing in them.
43:32
Talk a little bit about that and your all philosophy
43:35
and developing your skill sets.
43:37
You're obviously have great business minds, and so you constantly
43:41
seem to be investing in yourself and other physician- leaders.
43:44
We believe it's imperative that physicians play a very strong role
43:48
in leadership, whatever practice they work in.
43:52
Whether to the hospital, whether it's in a two man group or 170
43:56
man group or a sponsor practice.
43:59
And I learned a lot about leadership.
44:03
I was involved in the medical staff leadership at one of my hospitals.
44:05
I went to a lot of leadership seminars, and so I had to do things
44:09
and sort of got trained that way.
44:11
So without having people do that,
44:13
we were very interested in developing otolarangologists to be leaders,
44:17
and we were very excited and very happy when the Academy had that program start.
44:21
And two of our physicians,
44:22
one of them on the call here with us is going through the training.
44:27
And, you know,
44:28
I actually sent a questionnaire out to our all of our physicians last week,
44:32
people who are interested in gauging interest in becoming leaders.
44:35
Because we need to enable them and train them and
44:39
teach them how to do the things that a leader does.
44:42
It's it's very uncomfortable sometimes to have to speak to a colleague
44:46
who's acting out or who is over utilizing,
44:50
you know, how do you have those conversations?
44:52
How do you get someone to put their own personal
44:55
needs of the day aside to look at the big picture?
44:58
But if we don't do this, if otolarangologists don't do this,
45:03
we are going to be strictly employees and told what to do.
45:06
And to me, that is the death of what medicine means to me.
45:13
Yeah, that's a that's that would have been a great way to end.
45:15
That's that's ominous.
45:16
Meaning if we don't take charge we are culpable for that.
45:21
Rich physician leaders, you're 173 docs.
45:24
You have a governance model where physicians are leading.
45:27
You are actually in that driver's seat.
45:30
Yeah.
45:30
No, I think John covered a lot of the points.
45:32
And I do think that's one thing that we don't do a good job of doing
45:36
is training doctors to run businesses and residency,
45:39
which we ask them to do when they leave.
45:41
Nor do we teach them how to be leaders,
45:42
whether it's their small practice or in a bigger practice.
45:45
So having the Leadership Institute, I think, was very helpful to that.
45:47
I'm glad you guys came up with it.
45:49
But leadership is hard and it's a different skill set.
45:53
And so by having those basic skills allows us to to take control
45:56
and have a voice at the table.
45:57
I think the worst thing to John's point that we can be
45:59
is just employees where we're just told what to do.
46:02
I think that's really going to steal what we saw as what many reasons
46:06
when to business to ENT in general, was to be able
46:08
to make the calls to our patients and have that degree of independence.
46:11
And we really want to value and preserve that going forward.
46:15
And that's how we've really created
46:16
physician leadership as a core tenant of our business.
46:19
Yeah.
46:20
I'm going to give you each a final word.
46:22
But before I do ponder this question again, you don't have to answer anything.
46:26
We can always cut these off.
46:27
But I always like to know who's the last person you hired.
46:31
You don't have to give me their name, but kind of skill set
46:34
where they're going to practice, whether it's Texas,
46:36
Louisiana, other states and the last person that left?
46:39
So if you're okay to think about that, you might not have it at the fingertips.
46:43
But if either of you could think about
46:45
that somebody you're in the process of hiring now and and what do they thinking.
46:49
And somebody the last person that left.
46:51
And then one of you talk about the proportion of partners to doctors.
46:55
That to me was stunning.
46:57
So all three of those go ahead either of you.
46:59
We've been very successful in recruiting physicians.
47:02
I in my office I have two associates who started this summer,
47:06
finished a registry last year and they are general
47:10
otolarangologists who are learning how to practice under.
47:14
They came from anywhere in the country or just from Miami.
47:18
No one came.
47:19
One trained in Virginia, one trained in Maryland.
47:22
Thank you.
47:23
And we have we recruited people in Texas and we recruited people
47:27
in other parts of Florida.
47:28
And we're working on people in Louisiana.
47:30
So we do have people who are interested in coming to join us.
47:34
The last person to leave,
47:38
we we had a physician leave because his wife wasn't happy in Miami.
47:44
That's great. Yeah. Don't remember.
47:46
And then we had a few people retire
47:48
just due to natural course of a career, but I don't.
47:51
I love that, I love I love your honesty, even your quizzical face,
47:55
because you're looking at each other like, you know, which is great, right?
47:58
You don't want to say, oh, Rahul just left last week because he got mad.
48:02
He. People leave for social reasons and people retire.
48:05
I mean, those are the two kind of. That's what we want to see.
48:08
Rich, sorry. I don't mean to cut you off.
48:09
And then if one of you
48:10
can talk about associates versus partners, then I'll give you the final words.
48:14
Rich.
48:15
Yeah, I can cover both.
48:16
I'm going to take a slightly different tack than John.
48:19
We've been fortunate to have a lot of partnerships
48:20
with new practices, and we're currently in the process
48:23
of partnering with with a practice in West Texas who's part of a strategic
48:26
employer, had his own issues, decided to move ahead with us understanding
48:31
there would be a change.
48:32
And we are now given the opportunity to unlock value in this practice,
48:35
but also bring in house other services, allergy, otology, and head/neck.
48:39
His income is going to increase.
48:40
He's excited about being an operator and owner again
48:43
because he'll be an equity partner in the business, which is really exciting.
48:47
And then from a departure perspective, to John's point, we're very fortunate
48:50
to have a 92% retention rate over the last seven years,
48:53
meaning on the doctors have joined us.
48:54
92% are still with us.
48:56
The ones that have left, by and large, have been because of retirement,
49:00
save for the 1 or 2 of left for own personal reasons.
49:03
So we've been really fortunate to partner with the right partners
49:06
that want to stay with us long term.
49:08
And that's really exciting.
49:10
And your second question, Rahul, on this one was - I think I was stunned by
49:15
John started this by talking about how every physician has a path to partnership.
49:22
And you're very inclusive. The ratio is stunning.
49:25
Yeah.
49:25
We have above we have 90 plus percent of our partnership is partners.
49:30
There's less than 10% are associates at this time.
49:33
Everyone who we hire.
49:34
And this is one of my biggest selling point.
49:36
We hire future partners.
49:37
And if they're not a partner at this time either they're in path to partnership
49:41
and they've been with us
49:41
just a year or two, and they just have to finish out their associate component,
49:45
or they're at the tail end of their current have elected
49:47
to go back to being an associate because they just don't want to work full time.
49:49
They just pretty much want to get
49:50
a percentage of collections or salary because that fits their lifestyle more.
49:54
But we don't have any lifelong employees.
49:57
Everyone's a partner in making or a partner on the way to retirement.
50:01
Yeah, well, I'm laughing.
50:03
When you're the office today, can you tell that the lady who's
50:07
been at your practice older than my age, than I said hello?
50:10
It was different. You know who I'm talking about?
50:12
It was. It was.
50:13
Of. Course, rich.
50:16
Actually, John, I'll give you a final word.
50:18
Then rich, and then?
50:19
Then I'll end it. Any final thoughts, folks?
50:21
I'll let you.
50:22
Anything you want to address our about 6-7000 listeners?
50:26
Doctor Cooper then Doctor Vivero.
50:28
Yep. I'm going to go back to Frank Kromberg,
50:30
who is my friend and mentor, and we are better together.
50:35
That is the foundation of what we believe in.
50:37
And for every otolarangologist listening to this, we are not competitors
50:41
- we’re colleagues.
50:42
And we have to find a way to work together.
50:45
Whether you're in our practice, part of our MSO work next
50:49
to us, there's no reason to not cooperate with each other.
50:54
And we all have the same needs, wants, desires.
50:58
We all have the same issues and problems,
51:00
and we want to raise the tide for everybody to raise all the boat up.
51:04
So, you know, we have one way of doing things.
51:07
You know, we chose the path that we chose.
51:10
And I think it's been very successful and very attractive to a lot of people,
51:15
not for everybody.
51:16
But there's other ways to to, you know, be successful in practice.
51:20
And as long as you're happy, as long as you can go home at night
51:25
and be sure that you treated your patients the way that you want to be treated
51:29
without any outside influences.
51:30
To me, that's what medicine is all about, is
51:32
those relationships between the physician and the present and the patients, rather.
51:36
And again, we're all better together
51:40
having, you know, fighting between different facets
51:44
of private practice, employed physicians, academic practices.
51:49
We're all the same when it comes down to it.
51:51
We want to take care of patients.
51:52
Patients come first, people come first,
51:55
and medicine is love of my life.
51:59
I'm very happy to be doing it, I have not I would not change anything
52:02
in my life that I had decisions that I had made.
52:08
Yeah, and Rahul, I can echo John's comments.
52:11
I want to thank you personally for taking the time to come down here
52:13
and visit with us, and also give us time to answer questions on this podcast.
52:17
I think it's really important.
52:18
I find unfortunate when I go to a lot of meetings,
52:20
Elevate or the other, I guess, MSOs out in the community
52:23
oftentimes not given a voice.
52:25
We're oftentimes received a lot of criticism from people
52:27
who have not taken the opportunity to talk to us and or investigate
52:30
what we are actually doing.
52:32
So I applaud you for taking the time to do so.
52:34
We really are better together, as John has stated, and we really are trying
52:38
to improve the quality of care in the communities we’re in,
52:40
and we're trying to preserve the care there.
52:42
When there are a lot of committees have a hard time recruiting physicians,
52:45
there are a lot of practices
52:46
that have a hard time bringing resources to bear to improve their practices,
52:50
and we really like providing that resource. So.
52:53
and medicine's evolving,
52:54
and I think we need to evolve with it, whether it's technology,
52:57
whether it's ownership structures, whether it's the areas where we're
53:00
providing care and the networks are provide care.
53:03
And I think what we're doing here, one operation to provide this care.
53:08
And we always enjoy the opportunity to share what we're doing,
53:11
and we invite others to come down and visit with us in South Florida
53:13
or any markets that we're in and see what we're providing,
53:15
or talk to our partners in our markets to understand how they're doing.
53:19
Yeah, I want to highlight some of those points.
53:21
It doesn't mean you have to join you,
53:23
but you can learn and then take it back to your practice.
53:26
So your open arms are just awesome.
53:29
And it goes back to your point, Doctor Cooper, that together we're better.
53:34
Just two points.
53:35
First, much gratitude for everything you've done for the Academy
53:38
and teaching me that we are one otolaryngology.
53:41
Rich reminded me of that firmly, and I got it.
53:44
We're here that we all win together, so thanks Rich for that again.
53:48
Really appreciated that.
53:49
And John, I'm going to end with your daughter where it all starts.
53:52
All three wake up every day to win
53:55
so that she 20, 30 years from now, has a practice as good as us.
54:00
I mean, it gives me chills to think about it.
54:01
It's exactly why I took this job and exactly why you both wake up every day.
54:06
So thanks to you both and we'll see you at the annual meeting.
54:09
We'll see you at OTO Forum and people will find you.
54:12
Thank you, Doctor Cooper. Doctor Vivero.
54:14
Our colleagues from Elevate.
54:16
Thank you, thank you.
54:17
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54:20
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54:24
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54:25
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54:27
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54:29
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54:30
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54:34
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