Latest / Voices of Otolaryngology / Solo, Strategic, and Satisfied: 25 Years of Independent ENT Practice

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Solo, Strategic, and Satisfied: 25 Years of Independent ENT Practice · 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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My name is Rahul Shah and I'm your host.
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I'm super excited today to be with the new friend, Doctor Rajesh Kakani.
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Dr. Kakani, welcome.
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Nice to see you here again.
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And I admire your leadership.
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Well, I believe you listen to a lot of these podcasts.
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I don't think my mom or brother even listen to these, so thank you
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for listening.
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I listened to all of them and I watched some of them.
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Do you recall maybe what might be your favorite or one pearl you've picked up?
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You don't have to remember the who was the guest, but maybe one pearl.
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No, I think the key is you bring a real diverse
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a group of guests, and the key is you bring all aspects.
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And I think I sense that you, even though the audience is not there,
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you are imagining the audience from the academics, from the private practice,
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as well as the graduating residents
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who may benefit from your production.
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So that's wonderful.
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Well, I have much gratitude for you today on behalf of the Academy members,
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you and your, wife, through your family
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foundation, have endowed an international visiting scholars.
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Why don't you give the great news and, let's share that with our colleagues.
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Then we'll get into who you are, your practice,
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and and what you think we need to think about in the future of health care.
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So please, give us the great news
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and much gratitude for what you and your family have endowed.
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And I don't want to be the one giving the news, but
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I feel that Academy has been my professional home for 30 plus years,
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and I'm at that stage of life that I've realized I'm not going to take it with me.
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So this is a good time ti try to give back
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and what better to do than to the Academy?
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Since my residency days, I got involved with the Academy.
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I've been a member more than 30 plus years.
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I've attended practically every single one of the annual meetings.
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I got involved with the committees at the very beginning.
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I became a member of the International Otolaryngology Committee,
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and I think it has changed now, at that time, they set up international visiting
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scholarships, and I felt that I wanted to follow the footsteps of those,
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you know, pioneers who had previously set up the scholarships.
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So this was a perfect thing.
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What it does is it sets up a scholarship that allows one
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international visiting scholarship to come to the US,
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attend the Academy meeting, the academy meeting,
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and then Academy, give them a year membership
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and more importantly, Academy matches them for a two week
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period with the academic program in otolaryngology in the US,
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where they can be an observer,
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they can see how otolaryngology is practiced in this country.
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My hope is that all that information
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they would take back to their country, and these are young faculty members
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who probably have another 30 years of professional life.
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And my hope is that they would share it with their colleagues,
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their mentees, and more importantly,
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with their patients, because everything we do is all about our patients.
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So this was a great
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honor for us to be able to contribute.
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Thank you.
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Well, thank you very much.
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And to your wife and family and the foundation,
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we know it will benefit countless otolaryngologist and their patients.
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You mentioned residency.
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Let let's pull up stream.
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Where did you train?
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And tell us a little bit about, about that.
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And I'll keep interrupting you with questions
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to give us some cadence, but where where did you train, in residence?
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You try to be funny.
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I'm going to try to be a little funny as well.
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But I'm a slow learner.
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I was top of my medical school class, wanted to basically
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train in otolaryngology, and come back to my hometown
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and become a faculty because those were my role models.
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So I trained
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at some of the top places in India, and then I wanted during those times,
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all the books we read were authored by great American authors.
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I can name all of them, but I
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wanted to learn and see how
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otolaryngology is practiced in USA.
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So I came to USA 92, join a fellowship at Lenox
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Hill Hospital, and then I said, you know what?
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Might as well become a board certified?
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And I applied for residency.
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I managed for residency, did a full five year
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residency for seven years in India and then seven years here.
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When I finished, I wanted at that
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time to be in academics, and then I joined academics and I said, no, no, no.
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The sentence
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let me back up a second.
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So where did you do your residency?
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So that was at Stony Brook State University of New York, installable.
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And who you mentioned the word for word role models.
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And I think that's important when we think of medical students and residents.
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My favorite textbook was Deweese and Saunders’, as a medical student.
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Do you remember that red textbook about this and thick? Yeah.
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And it took you from embryology all the way to various.
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I have that at home.
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I love it so you were at Lenox Hill in a fellowship pre pre residency.
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Then you went to, Stony Brook, is that right?
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Full accredited residencey at Stoney Brook. Yes.
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Who were your role models there?
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Who did you, have an affinity to learning from?
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So at Lenox Hill, I got in touch with the stalwarts
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like Doctor Wilbur Gould, Stanley Bloggin, Ernie
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Comisar, Ron Hoffman.
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I mean, amazing top well known
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otolaryngologists in the world at Stony Brook.
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I had an honor of working with Doctor Arnie Katz.
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And Eric Smouha, Max April and others.
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So you are finishing up training,
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and we often think about our residents, fellows and young physicians.
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And you said, academics.
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I've done 14 years of training.
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That's my pathway.
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But you're in a solo private practice for 30 years.
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How did you go from here to here?
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What was going through your mind?
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So I did join
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a job, thinking I'm going to be in academics.
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And I got there, and I realized that to grow in academics
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means I'm going to have to do a lot of publications.
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And I realized that my strength
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was listening to one patient at a time.
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And the third part was I realized, I'm a micromanager, so
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I need to be able to get my own history, do my own examination plan my own case.
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Also, growing up, you know,
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my family, we love being small business. And,
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having be on your own boss.
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So I said, no. What?
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I'm going to start from (inaudible) a solo practice.
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Even when I joined the job, I told them that
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I may do that and they were kind enough.
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I have at that in writing.
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So, that allowed me
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to pivot from, academic to a solo practice.
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The other thing that happened was,
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as I was in the job, they offered me, you know,
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the chiefship of a department at a federal hospital.
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And one of my mentors said, look, if you want to ever try
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private practice, this would be the time to try it.
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Once you are in -
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an academic or in a job more than ten years,
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then you are going to be more scared to pivot.
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Yeah, so give it a try and one thing led to other and.
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I thought it was very interesting.
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You found your strengths
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and you used micromanagement as a superpower.
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I don't criticize it, but it was very interesting that you said,
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look, I want to run my own show and I'm going to stay that way.
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And you turned those strengths into a highly successful practice.
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Isn't that some good wisdom there?
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You know that what you said.
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Look, my strength is listening, not grant writing, not doing research
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driven hypothesis will let those people be highly successful.
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That took a lot of conviction.
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You were betting on yourself.
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I guess you knew your strengths.
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Yeah.
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I mean, it was a major decision.
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The other thing that helped at that time
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was my wife had a job and we had health insurance,
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so I could take a risk of
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starting my own practice.
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Of course, it was a calculated risk.
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So you started in practice.
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Year one, year two, year three.
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What were you seeing?
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What were your common things in the office?
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And then so answer that and then I'm going to fast forward to what you see today.
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And I want our young learners to think about how practices evolve.
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So you come out,
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you hang the shingle, you know, you have health insurance from your wife,
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but you got to take all comers, everyone that comes in your door.
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So what did you start seeing?
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Right.
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So again, I did an I graduated.
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In New York in a highly competitive market.
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Go ahead.
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Yeah. Thank you for bringing that up as well.
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The other thing I decided I want to be where there are
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a lot of otolaryngologists, because one of my mentors said it's a lake.
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There are a lot of small sailboats.
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If you go
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to put another small sailboat, it's not going to affect the other sailboats.
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So it was a slow process.
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I still kept part time job,
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and then I took privileges at some smaller hospitals.
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And those hospitals,
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believe it or not, they need ENT.
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And let me pause there because I want I don't want our audience to miss that.
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So you said, okay, I don't want to do academics.
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I'm gonna hang up a shingle, but it's going to be half shingle.
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Okay, here's here's my camera here.
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I can't focus on me. It's a half shingle, right?
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I'm going to still be on staff, maybe get some ER calls
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to have the cash flow coming in while my shingle gets fully developed.
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Is that right, Doctor Kakani?
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That is exactly how I did it. Yes.
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And how long did you do that?
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Let's say
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maybe hybrid model before you were able to completely make that shingle full?
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So I was able to wean off of my job
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at this hospital in two years from the start.
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And then what did you see?
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What kind of patients were you seeing in the office?
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Obviously, you'd bring them from the hospital to your practice,
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but but what was coming through the door back 30 years or so?
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Again, some of these hospitals have pediatric patients.
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I am not pedatric otolaryngology trained.
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So somehow my practice was more
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adult practice than pediatric.
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The other thing that happened, fortunately, having been trained
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at so many places with so many good people,
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I felt comfortable doing a full breadth of otolaryngology.
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And somehow they needed
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this hospital, needed a thyroid/parathyroid surgeon.
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I got busy with thyroid/parathyroid and somehow I got known
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in the community for doing thyroid/parathyroids.
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I would obviously see the patients
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in the office for all the sinusitis and everything else.
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Go back a second.
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You said something I'm still struggling with.
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I think it's interesting.
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Somebody taught you go to where there are a lot of ENTs.
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You glossed over that.
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That's somewhat paradoxical because people coming out say, “I’m
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gonna hang my shingle where nobody's around me for three hours.”
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Explain that for our audience and a young learner.
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So this is a longer,
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description, but.
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You know, you want to have
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of a shop.
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You want to have a restaurant where there are a lot of other restaurants.
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Okay?
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You want to have a hotel
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where there are a lot of other hotels, because that's where the customers
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are coming.
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So the logic is and then you're going to need coverage, you're going to go away.
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You're going to need friends.
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So that is where you know, there is all a need, an infrastructure is there.
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So I felt I didn't want to be
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away from where the need is.
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And I didn't want to be away from where the competition is.
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Very, very interesting.
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There's an economic business principle that you're alluding to.
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That's why if you're driving on 95 north or south, you'll see an area
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and there's seven hotels and you're like, why in the world is that there?
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There's there's some business principles, but that shows you
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actually how difficult it is for solo rural practices.
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Anyways, that, that that's another story.
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So you started out
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with head and neck, blood, but you also had sinus coming in the door.
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Everything adult.
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Right. Okay.
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So so yes. Everything adult.
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And then how did the practice evolve?
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Let's look at it in maybe ten year chunks.
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So then you're ten, 12 years into the practice.
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Children are getting older, practice is humming.
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Was it still thyroid, head and neck, and sinus?
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What did the practice evolve to?
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I'm going to quote my guru, Doctor Ashok Shaha.
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He jokingly says: “In otolaryngology,
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by 35 we learn how to operate, by 45 we learn when to operate, and by 55
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we learn when not to operate.” So again, I wanted to do surgery
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earlier years and a lot of adult, but I would do the full breadth.
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And the other thing that happens is when you go to these hospitals, take calls,
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the staff knows you, the nurses knows you know you, the other doctors know you.
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Their families start to come to you.
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Okay.
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And yes, initially there was a lot more operating
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and then slowly there was more office.
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I started to listen to patients.
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I took a training and a fellowship
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in America at the American Academy of Otolaryngic Allergy.
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So I became allergy trained as well.
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So office slowly sort of pivoted
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from more surgery, which I still do do more office,
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more hearing loss, more cerumen,
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more dizziness, more allergy and so forth.
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I admire Doctor Ashok Shaha as well,
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and I might call him after this, to ask him what happens at 65?
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You're still operating.
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Maybe you're grateful to be operating, right?
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Or grateful to be seeing patients that’s probably true, Doctor Kakani.
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So now now help me
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because thyroid parathyroid you were trained for 14 years
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exquisitely trained then in sinus, but then you started learning
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general otolaryngology management of vestibular and dizziness.
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How did you learn?
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Where did you find that time?
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Was it medical staff meetings?
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Was it the camaraderie and partners in your hospital?
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How did you start evolving?
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So I absolutely the most important thing, most important message
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from this thing I want to convey to my friends is keep learning.
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Please don't stop learning.
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So I attend obviously Academy meetings and every opportunity for CME,
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not only in otolaryngology, but in other related fields.
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So I continued to learn.
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I had some training without,
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you know, dizziness during my training in India.
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And I realized that the diagnosis of a dizzy patient,
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at least 90% depends on a good detailed history.
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Okay.
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So it was a natural sort of progression
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to listen to the patients and try to make a guess
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of their cause of dizziness and try to help them get better.
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I am not a neurotologist.
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I am not, you know, I mean, there are certain patients
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who absolutely need a fellowship trained neurotologist,
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and I refer them to my colleagues in the area all the time.
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Yeah, it's very interesting.
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We used to call them drug lunches or device lunches, and they stopped.
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They stopped in the early 2000s, due to government regulations.
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It's very unfortunate,
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because I used to learn a lot from those sales rep and pharmaceutical reps.
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And, you know, there's CME,
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but there's also learning what new technology is out there.
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What indications are that I was just a a random commercial.
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But but frustrating.
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And I like your point about, learning from every specialty.
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You might go to a rheumatology, grand rounds and learn about biologics.
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Yeah.
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I mean, the flip side is: now we have Zoom, now we have YouTube.
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There are so many resources to learn.
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Now you don't have to go to those drug lunches to learn.
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But I have a feeling you like human contact.
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I do like human contact.
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But by the same token, with the Sunshine Act, I did that.
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The other thing, I decided to be at least twice as good. So
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even if I go to those sponsored meetings, I try not to partake in the food.
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And yeah, so you have to be careful.
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To each their own. Yes.
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So talk a little bit about, in office based procedures.
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Do you do them? Did you do them?
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How has that evolved? What are the pros and cons?
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What advice do you give to solo practitioners?
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How do you build that infrastructure?
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New York is a tough market to practice, so there's a lot of scrutiny,
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on health regulation but also peers and referring doctors.
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So talk a little bit about in-office based procedure.
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So the key thing is two parts.
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One, treat every patient as if that was your family member okay.
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And number two,
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if you're going to be in a solo practice, you got to be at least twice as good.
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And the third thing, which is my principle
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in everything in life, you know, you got to expect the unexpected.
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My joke is I always travel with two spare tires in my car.
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You got to have to.
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There will be complications if you're going to
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do any surgical procedure, whether in the office.
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So if you follow those three principles, I think you're going to be okay.
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And what
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what office based procedures did you start with?
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What have you evolved with? What do you do in present day?
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Now, again, I am not doing any major invasive office based procedures.
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So again, everybody will have their own business models.
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But my business model has been to have an ethical practice
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and an ethical marketing.
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And the best marketing is when I show up into the hospital
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and there are at least ten people seeing me do things, there
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is, in the ER, nurses I see.
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I see, so I understand what you mean.
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You. Yeah, I get it, I get it.
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You want people to see what you do.
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And it gives, your patients.
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They feel assuaged. I understand that makes sense.
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So I do more things in the hospital then in the office.
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How did you manage call as a solo practitioner?
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And I'll ask you then I probably should ask your children.
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So, yes, the call was tough.
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And in those days we did not get compensated for call.
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So again, the main rule there has been it takes less effort
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to go see the patient yourself than to try to manage a patient on the phone.
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Okay.
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If you get a phone call for a nosebleed at 10:00, you better go there at 10:00
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in the evening.
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Take care of that nosebleed.
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Otherwise they're going to wake you up at 2 a.m..
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Okay? So, yes, call was tough.
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I took care of it and treated every patient.
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So were you In a shared call group?
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How did you do that? Yeah.
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So once your colleagues
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know that you're in the area, everybody needs call coverage.
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As soon as my colleagues in the area knew that I was here,
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I was not going anywhere.
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They said, why don't you join our call group?
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We've got to cover for each other.
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That's
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how you generated patients from referrals, am I right?
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Right. And goodwill.
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That's the other message.
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Please don't step on toes of your colleagues.
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You know, everybody is trying to take good care of their patients.
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Yeah.
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You know help them out.
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And that has helped me.
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I think that’s a good message for our Academy.
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A member taught me that, we want all otolaryngologist to win, right?
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I like that, yeah.
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That’s how our patients get the best care.
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Yeah.
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So your call group as a solo practitioner,
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was it one hospital you covered or more than one?
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So I primarily covered in
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in suburban New York area, three hospitals.
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And I did have various arrangements for covering.
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So when I would go away my friends would cover
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and I would cover for them.
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Yeah.
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What I'm trying to do is help establish for members that are thinking
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about solo practices, what catchment area you need, what volume you need, right.
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To generate that referrals.
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Yeah.
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So again that the other message: have diversification.
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You know, if you're going to be in that area,
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if you're going to have two hospitals
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get approval, if you're going to be in solo practice
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and they allow you and again, the model has changed.
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You know, a lot of hospitals are now - You get employed.
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Yeah.
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Employed model.
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And you may not be able to get it.
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But if you can: two hospitals this way you have some diversification.
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Did you ever look at the employed model where the hospitals came
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knocking and said Doctor Kakani, come, come to us.
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Did you like that or were you established you might have been too established?
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When this trend has started.
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I might start looking now.
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Oh interesting.
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But but but the thing is,
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you know, this negotiations, the submitting the data are going
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through the process.
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To me that's really time consuming.
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Okay.
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I would rather spend the time seeing 2 or 3 more patients and keep my cash flow.
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So, so far, as much as the grass looks greener on the other side of the fence,
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I have stayed solo.
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Yeah.
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Talk a little bit about back office functions.
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So I see you.
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You're the face of the practice. Who?
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Who else is in your office?
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How many exam rooms do you have?
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What is the back office?
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Is it virtual? Remote offshore?
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Talk a little bit. Whatever makes you comfortable. Please.
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No, I won't do offshore.
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I just, didn't, you know, HIPAA compliance, so no offshore operations.
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Anybody thinking of solo practice,
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you're going to have to be the computer tech guy.
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You're going to have to be the janitor.
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You're going to have to plunge the toilet,
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and you're going to have to look over the building.
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Okay?
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So ultimately, the budget would stop with the solo doctor.
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But I have a great team.
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I have a billing company,
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I meet with them periodically and go over the stuff.
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I have three wonderful people in the front.
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I have two audiologists who both combine work
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as one FTE and I
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about two years ago found a wonderful, experienced, physician assistant.
24:18
She is on my team as well, so that allows me to take care of patients.
24:23
Again, the other key in solo practice is
24:27
please take great care of your team members.
24:30
Okay?
24:31
Happy employees, happy customers.
24:34
So I counted roughly six
24:38
folks, bodies in the suite, and then a back office
24:41
that helps you with your, managed services?
24:44
That is correct.
24:46
Yeah. Thank you for explaining that.
24:48
And then
24:50
when we look at the, makeup,
24:54
the constituency of your office, how does the exam rooms look?
24:58
How do you keep the flow going?
24:59
Just describe to people, that flow and how you manage it with,
25:03
physician assistant and you seeing patients and audiology.
25:08
You'll have to bear with me.
25:09
One more joke.
25:11
I tell people I don't work about 20 to 30 friends come one by one by appointment.
25:17
You have a small talk, each one of them as they are leaving, they thank me.
25:22
And somehow I get paid for it.
25:24
Okay, so I have
25:27
four exam rooms.
25:29
Two of them are set up with the flexible or rigid endoscopes.
25:33
One of them has a strobe,
25:34
and then two of them are set up with the operating microscope.
25:37
I don't do anything even in the external auditory canal
25:41
without the operating microscope.
25:42
Now, and then I have a fully functional, wonderful audiology suite.
25:49
We have rooms like this one
25:52
for three of us to sit down and work on our computers.
25:55
And then there is a waiting area, and then there is computers
26:00
and desks for the front desk staff.
26:02
So I keep dancing between the four exam rooms.
26:07
Me and my PA, if somebody comes,
26:09
if we have to do, let's say, a flexible laryngoscope, they
26:13
I would spray the person in room one.
26:17
Yeah of course. Yeah yeah yeah.
26:19
Go to room two listen and then come back, and then do - If
26:22
I knew the way real estate would go 30 years ago, I would have bought a suite.
26:28
If I was Doctor Kakani and watched New York real estate go.
26:31
But that's impossible.
26:33
Coming right out to afford that, etc..
26:36
Do you, take your space?
26:38
Do you own your building? How does that work?
26:41
So that's the other thing.
26:42
I didn't want to be in a, like in a small silo.
26:45
I wanted to be in a big professional building.
26:48
So I started out with a sublet.
26:52
And when the practice got busy, when this space became available,
26:57
I bought this office condo again.
27:00
You know, that was real estate entity in the family that.
27:02
But it's in a bigger it's in a bigger.
27:04
How big is the building?
27:06
55,000ft² flat,
27:08
one story building, a lot of parking outside.
27:12
Okay. And
27:14
you are segmented?
27:15
You have your part of it?
27:18
Yes. My practice is 1900 square feet out of that 55,000.
27:22
Yeah, yeah, yeah.
27:23
There are other specialties in the building.
27:25
I thought it was a really interesting pearl.
27:27
You didn't want to be on an island.
27:29
And you think about it.
27:31
You have, you know, maybe 5% of the space there,
27:35
but the other 95% are potential referrals,
27:39
correct?
27:40
You know, you it's the visibility, okay.
27:42
People walk down the hall and they see an ENT board outside.
27:46
Okay. Yeah. Yeah.
27:47
Is there a lab, that you can use in the building or radiology?
27:52
Or no, it's all physicians.
27:53
No. There are labs also in the building.
27:56
And, yes, I can send it to them.
27:59
No ownership or anything.
28:01
We send it to them and that's it.
28:02
Yeah.
28:03
I just want people to envision what a solo practice with one advanced
28:07
practice provider, two audiologists looks like in their mind,
28:10
especially in New York. So I appreciate that.
28:12
And where's the practice located?
28:14
What suburb or what city?
28:16
So we are in what is called Nassau County, which is part of the region
28:20
called Long Island.
28:21
So about 25 miles east of New York City.
28:25
Yeah. Thank you for that.
28:27
Helping our folks understand.
28:29
So let's end with the future.
28:32
What do you see out there?
28:33
You've lived through a lot of cycles.
28:34
You've had exquisite training.
28:36
You practice in New York.
28:38
What do you think the next ten years look like for solo practitioners?
28:42
Not your office, per se.
28:43
But if you are there representing solo practice,
28:47
American otolaryngology medicine, what does it look like?
28:52
So again, I do not know the future, but
28:55
what I do know is that more things change, more they remain the same.
28:58
And there are some basic principles which would stay.
29:03
We would need doctors.
29:05
We would need otolaryngologists.
29:07
And board certified otolaryngologists are some of the best trained in the world.
29:13
So people are going to need us.
29:16
And if we can continue to provide
29:20
good service, we would have food on the table.
29:23
I this is why I'm a member of the Academy,
29:26
because I need you to sort of lobby
29:30
for me in Washington, DC for,
29:35
you know, better compensation and better things.
29:38
And yes, obviously there is consolidation.
29:42
Academic places, you know, they serve a great need,
29:47
but people would need access to care.
29:50
And with the workforce not being there,
29:53
if given certain can run an ENT urgent care
29:59
with physician assistants and nurse practicianers.
30:03
I think if there is an entrepreneurial, enterprising
30:07
doctor,
30:08
if you want to run a practice, he can run it, start it as an urgent care,
30:12
ENT urgent care.
30:13
That's what I think my practice is, you know, and then there is work
30:18
for everybody.
30:19
The main thing is take care of your own health,
30:22
your family, and you got to enjoy what you do.
30:27
Would you do it again?
30:29
Solo practice. Did you make the right decision?
30:31
Did you find the place for a micromanager who wants to run a practice
30:37
and loves taking histories and talking to patients?
30:40
Would you do it again?
30:42
So far as I told you, I don't work,
30:44
so I am enjoying the way it is.
30:47
I don't know the future.
30:49
Certainly.
30:50
You know, as I said, sometimes the grass looks greener on the other side,
30:54
but for now, I'm having fun.
30:57
Well, one of the highlights of my job is meeting people.
31:00
Thank you for calling me.
31:02
I think in November, we struck up a friendship, followed
31:06
by your family foundation donation to the International Visiting Scholars.
31:10
Since then, we've exchanged phone calls.
31:12
And I appreciate learning from you, because we take that on Capitol Hill
31:16
and we work with health policy and insurers.
31:19
So I'm blessed to make a new friend.
31:20
Doctor Kakani, thank you for sharing your wisdom with our audience.
31:24
And they know how to reach you.
31:26
Doctor Rajesh Kakani, thank you.
31:28
Thank you and thank you for your leadership.
31:30
Thank you for what you do.
31:32
And please, please, please keep, you know, sort of advocating for us
31:37
all over the place. Thank you.
31:39
we hope today's episode sparked some fresh ideas.
31:42
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31:46
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31:47
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31:49
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