086 The Different Looks of Independent Peds Practice and Advocacy at the AAP, Dr. Michael Martin MD FAAP

Dr. Martin created Einstein Pediatrics in 2016. Living in Vienna, Dr. Martin is not only a physician to many local kids, but an active member of the community.

 Prior to starting his own practice, Dr. Martin spent over 8 years as a managing partner and clinical researcher at Advanced Pediatrics.  He has over 20 years of clinical experience and spent over 10 years as a clinical site investigator on studies related to many of today's vaccines including those for flu, HPV, and pneumococcus.

He served 2 years as the President of the Virginia Chapter of the American Academy of Pediatrics (AAP) during the COVID pandemic where he regularly worked with the governor's office and the Virginia Department of Health, representing children and pediatricians.  He continues to serve in leadership at the AAP and on Virginia's Immunization Coalition, ImmunizeVA.

 He takes a special interest in childhood vaccinations, child mental health, and particularly, Attention Deficit Disorder.  He has received multiple awards and recognition for his work in advocacy, education, and leadership in the field of pediatrics.  Dr. Martin is regularly listed as a Washingtonian Top Doctor and a Northern Virginia Magazine Top Doctor and even early in his career recognized as a "Rising Star" in the Washington Post. 

 Dr. Martin is married and has a teenage son and daughter.  He is an avid tennis player who you will find regularly at the Fairfax Racquet Club. 

Transcript

The Different Looks of independent Peds Practice and Advocacy at the AAP

[00:00:00] Dr. Bravo: Good afternoon, George. It's Tuesday morning and I'm in Manasas, Virginia, covering the office of a great friend of us and a P United fellow member, Bryan? Yes. And a great guest today. Dr. Michael Martin, who's a dear friend of us. 

[00:00:17] Dr. Rogu: Okay. And this topic today is gonna be the different looks of independent pediatric practice and advocacy at the AAP level, 

[00:00:24] Dr. Bravo: welcome Mike. How are you? 

[00:00:26] Dr. Martin: I'm good. Thanks for having me, guys. This is fun. I I enjoy doing these. It's, 

[00:00:30] Dr. Bravo: it's a pleasure. So Mike, why did you become a pediatrician? Oh, geez. 

[00:00:35] Dr. Martin: And in one minute or less, in one minute or less. For me it's, it's a unique juxtaposition of, of things.

I've always done stuff with kids, which I think every pediatrician said, right. I, I coached, I, I just, I loved working with kids and it really appealed to my analytics side too, and, and love of science. And, you know, I played around in college with doing research and going that path and just realized I'm a people person.

 I need to be up and moving and doing different things and having a job that I'm not sitting at a desk and I constantly, constantly changes and, and provides different opportunities. And so peds, peds was at, it's, yeah, very early on. 

[00:01:20] Dr. Bravo: Now, you started your career in Northern Virginia with Dr. Schwartz's left us, right? I did. And you were there for 10 years. What, what was it like to work with Dr. Schwartz? 

[00:01:31] Dr. Martin: Yeah, it was, you know, right from the get go. It was an interesting I experience when I was even applying for the position. The common theme you'll see with me is I don't like the subtle doing one thing I like.

I think you'll see that with a lot of entrepreneurs and practice owners. We need to have different things to dabble in, and there's no one that exemplified that more than Dr. Schwartz. And I remember meeting him, I, was at a long, long week of interviews through Virginia and he was my last one.

And I, I just remember showing up and he is like, it was, he was just electric in tr talking about all the thi different things he does in terms of teaching the research. It was, it was an incident connection. I was just like, this is someone, and especially after some of the interviews I had had, I was like, I don't know if I can, you know, I didn't know if the other places were really a right fit for me.

And, and it just, it just clicked right away. And I remember coming home talking to my wife and, well, how did it go? And I was like, I think he offered me the jobs, but I'm not exactly sure. 

[00:02:32] Dr. Bravo: He, he was a, he was a genius. I mean, he, he really was a genius. He 

[00:02:37] Dr. Martin: was a, he is a, yeah, a big loss to pediatrics. Not being around, but he was a mentor to me.

I mean, clinically, I learned so much from him. And he really let me explore my interests in a way that I don't think anyone else would. , I remember even like about a year in, you know, so I'm only in practice a year. I'm still learning what I'm doing. I don't know what I'm doing. Right. One year out of training and the program at Inova needed someone to really run the continuity clinic, which was kind of a patchwork at that point.

It, it had kind of fallen apart with a curriculum, didn't really have one. And so this great opportunity came up. I got to know just in that year, he kept bringing me to grand rounds and meeting people. And so they got to know me and, and were like, Hey, we'd like you to take this, is a program director position and really revamp the continuity, you know, program.

And I, like, obviously I had to go to my boss and say, I'm gonna need some time to do this. How do you feel about this? And I'm like, he, he didn't blink What? He's like, you gotta do it. I'm like, oh, okay. And I don't, I don't know many bosses that a year out that'd be like, that take you away from, you know, generating and you know, revenue and seeing, no, he, 

[00:03:48] Dr. Bravo: he would've let you do that.

What what I remember about him is oh, he would shred people to pieces in those meetings. And then, you know, the other thing I remember about, about him was His technique of cleaning the nose and the kids full filled the bulb syringe with saline water and squirted, and then the mu kazuko flying out to the

[00:04:08] Dr. Martin: think ears, ears and noses need to be cleaned. 

[00:04:13] Dr. Bravo: I always ask him, how do you stay in practice with all these boujee women out here in Northern Virginia? Don't they like start hitting you when you do that? They're like, no, no, they're used to me and I'll do it. Oh, well that was really fun. Why did you leave that practice? You were there for 10 years. 

[00:04:29] Dr. Martin: I was, and I mean, it was an amazing experience and I got to a part where I was really doing, for me, I think we just, I came to a path in the road where I just had very different, Vision for managing. And, and this is where I'm so grateful for him, cuz I mean, during that time when I was there, I really got to stretch my legs and really get to learn how to run a practice.

And, and in some ways ex, you know, tried different things out. I took business classes while I was there and he really kind of gave me the reins. But I think the la largest thing, we just had very different visions of where the practice was going as we were getting larger. And, and so it was just a time I think was the right time for me, me to leave at that point.

What were those differences? Oh, you're getting into the tough questions now. Yeah. 

[00:05:15] Dr. Rogu: I mean, differences of, of practice, that's like a 

[00:05:18] Dr. Martin: standard. It's not the, it wasn't, it wasn't the clinical stuff. It really had to do with how the practice runs, putting, moving pieces of the puzzle in different places. So in terms of staffing, how, how we staffed mm-hmm.

I had put together a pretty extensive business plan and was, was starting to initiate that. And you know, that with that comes unease, right? It's change. Yeah. And people's roles are changing and so it's tough. I mean, I've, been through different places where those kinds of changes occur and I can see how it ruffles people's feathers and that uncertainty is tough for folks.

And you try to guide them through. But I think that is where some friction occurred. You know, it's, and it, rather than drive to further friction, it just seemed the right decision to step away, let him run things the way he, he saw fit. 

[00:06:09] Dr. Rogu: Right? Yeah. I guess they didn't want to change and pivot.

They just want to continue 

[00:06:14] Dr. Bravo: to 

[00:06:14] Dr. Martin: coast. Yeah. I, I think that's the, it's, it's a disruption, right? And so it's, you have to suddenly and it's just tough. It's like you've been doing things a certain way. Yeah. It's working. But as we know, if you don't change, it's, remember with my senior, 

[00:06:30] Dr. Rogu: with my senior partner, when it was time for the ehr, he says, why do we want to do an ehr?

It's been working like this for 30 years, so why would I wanna put an ehr? You know, that's what they, they all do that because it towards the end of their career, so why bother? 

[00:06:45] Dr. Bravo: Right. Well, I had a famous pediatrician tell me how bad computers were, and I did remind him that, you know, at some point we were teething urine to diagnose diabetes.

And he told me that's a small price to pay to get rid of that machine.

So that's funny. He was kidding. But it was really funny. So then you've had tremendous success at Einstein's Pediatrics. Yeah, I've been, and probably your wife day is more successful than you are. 

[00:07:13] Dr. Martin: Oh, I would a hundred percent. 

[00:07:16] Dr. Bravo: How, how and so for those people that don't know what they did in her last business venture, what did she Yeah, 

[00:07:22] Dr. Martin: so she, I'm super proud of her.

So she and she, you know, she had a path where she worked for other companies, a lot of startups, and got a sense of what that looked like. A lot of them went bust, so she saw failure too. She had a back injury, actually. She had a car accident and had a back injury. And at that time was, you know, it was hard for her to sit, so she needed a desk that would allow her to work at, but not sit which now they're on every target in every store.

Right. But she realized there was an opportunity there that at that time when she started there weren't really standing desks. And, and so yeah, that was where sh when she launched her own company, she started in our basement. At our old house. That was our warehouse for, for a while. She worked, actually works with my dad.

My dad helped her design her first desk, which was really cool to see them work together. So he did some prototypes cuz he had carpentry skills. That's what's always funny. It's like day's not an engineer. She's, she's not, you know, she had this company would, you know, building furniture in the beginning and that really wasn't her skillset.

Her skillset was in analytics and marketing. It was very, very much kind of a stretch for her learning how to do production stuff. And yeah, the company took off. She was one of the first three stand really decent sized standing desk places in the us. She became kind of a darling of Amazon and spoke I know at a few big conferences they had invited her to and.

Invited her to Capitol Hill to speak on behalf of small businesses. Wow. Yeah, it was really cool. And you sold the company 

[00:08:55] Dr. Bravo: for millions and millions, right? 

[00:08:56] Dr. Martin: Yep. So I cannot disclose the amounts, but yeah, I mean, she, she built the company up and like a lot of entrepreneurs at that point, she mean she wasn't wanting to have a large company that she served as c e o.

So she sold to a larger corporation. And yeah. Nice. Nice. Now she's onto, right now, right now she's, she's helping me with my practice, but she's actually onto another entrepreneur. She's got another project she's working on now, which I can't disclose yet. 

[00:09:20] Dr. Bravo: Okay. So how does her way of thinking influence the way you manage your pediatric office?

[00:09:29] Dr. Martin: It was interesting. So when I started doing my business, I, when I started, you know, at advance, started doing more of the business management side. I realized through her how important the marketing, and really marketing to me was just, you know, it's another term for us motivating people to do good things for themselves.

I mean, it's like, people say marketing, they're ill. That's, you know, you're sailing stuff, you're trying to convince people of stuff they don't need, but I'm like, actually it's motivational interviewing and how you present things to folks to motivate them to change and stuff. And so a lot of what I learned through her was, was that piece of things.

And certainly starting a business, you know, getting the word out, learning how to, you know, get people to know when I started my practice where I was, what I was doing and, and what was different about what we were doing was a piece of it. I still remember, I was doing, so she had a lot of experience with her business and taught me a lot about, you know, just Google ads and really.

Getting up on the high, high end of the list and stuff. And at that time it was, it was, nobody was doing it. it actually was really, really cheap. I did not have to spend money, much money on the Google ads and stuff, cuz no one was in the space at that time. Totally different now, but it, it was, it was interesting.

 I definitely was able to get ahead on, on that piece compared to others where people just weren't occupying that space and, and that, that was tremendously helpful. 

[00:10:57] Dr. Bravo: Do you think that, do you think there's a lot of pediatricians putting Google ads now? 

[00:11:01] Dr. Martin: There're definitely when I've looked, there's definitely more. I would say it's more the big hos because I was, what I was surprised the big hospital systems really weren't occupying that space yet either. And now they are. So what I generally see is not necessarily smaller practices, but like more of the large. Practices and hospital systems putting, putting stuff up now, cuz they have the budgets, right? Yes. They have the marketing team. So they have the people doing that. 

[00:11:27] Dr. Rogu: Yeah. In the old days marketing was a bad word. 

[00:11:31] Dr. Martin: I still feel like when I talk to folks about it, yeah. I still feel people like Ill, that's not what we're about. I really think look more at the psychology of what it is.

Mm-hmm. It's like you're doing something amazing in your office. You need people to come and experience that. It's good for their kids. They need to be vaccinated and, you know, whether you wanna use the word motivate or market, I mean, that's, they're, they're in many ways synonymous.

[00:11:58] Dr. Bravo: You know, we, we get in front of ourselves as pediatricians.

Look, we've been marketing since pediatrics has been a profession. And it used to be called the Yellow Book and the AP directory. And then we went to the nursery and we brought cookies to the nursery nurses so that they liked us and we were very polite to them so that they would let send us patients.

You got it. And then we played golf with the obstetricians. You know, when there was a thing that doctors had time, money to do because we would show up for the C-sections and they liked us, and then they would send us patients. And so we've been marketing since there was been a pediatric specialty. And, you know, we need to make money in order to stay in business.

So, man, money making is not a dirty word, and everything in life is a sale when I'm, but that's very weird. 

[00:12:46] Dr. Rogu: If you Google any physician, or most of the time the physicians, their name does not even appear with their practice. You'll get health grades and OU appear with a hospital or US Health News, but their practice name does not appear almost ever.

[00:13:03] Dr. Bravo: It's hard to find them. 

[00:13:04] Dr. Martin: Yeah. And those are the folks that don't realize that the importance of that stuff and that they're letting others kind of dictate how people view them, see them. And, and it's hard. I mean, it is another piece of what we do being added and, you know, another thing added to the pile.

Yes. But that's why you, you know, you try to get a good team around you that can help you where, where your, where your blind spots are, where you don't have the skills, you don't have to have all these skills. You just need to have people that do have those that can work with you. 

[00:13:33] Dr. Bravo: Great. And then what is Trusted Doctors what, what was the motivation to stand that group 

[00:13:39] Dr. Martin: up?

Yeah, so Trusted Doctors is essentially the brainchild of Sandy Chung. People that may have heard of her be president. Right. I've been friends with Sandy gosh. Gosh, since 2006, seven when I first moved to the area, I got to know her real early and, and she brought me on as, as a board member at the local medical society in, in Northern Virginia.

So we had been talk, she had been talking to me a long time about this idea of, of allowing for our practices to coexist and collaborate , but utilize our togetherness to negotiate better contracts kind of share resources that are redundant that we all need. And so yeah, out of that came trusted doctors.

, we have multiple, we call 'em divisions, what used to be our individual practices. They're technically trusted. Doctor divisions, we share a tax id. Our billing goes through a central agent, you know, a central part of the organization. And then you know, we're working together on clinical and clinical goals in terms of, so it's 

[00:14:47] Dr. Bravo: very much a practice without walls model.

Yeah, and 

[00:14:51] Dr. Martin: that's right. But, you know, I think the important thing, and I think what Sandy, I think a barrier, and I will tell you Dr. Schwartz would like it definitely would've been a barrier for him, is that, you know, that desire to continue to be autonomous and make decisions on the day-to-day and how you practice.

And I think trusted doctors has struck, stricken that nice balance. There are certain things that we certainly, and I, and I think for most of us, it's the stuff that we, we know are important, but we're not. Too much into the fine details of how our 401K is administered and the health plan stuff that, you know, that we can, we can all compromise on those things.

But still at the practice level, the patients when they walk in my practice, th you know, from the time before I was part of Trusted Doctors to after, I don't think they would be able to tell you the difference. Right. 

[00:15:40] Dr. Bravo: And, and are you all an OP or you can choose your No, so we've, 

[00:15:44] Dr. Martin: we've narrowed it down.

There's two. So there's a I think three of us are on op, the rest are on eClinical. 

[00:15:51] Dr. Bravo: Yeah. I hope you don't have to change the clinical. 

[00:15:54] Dr. Martin: So, the plan, we, there's enough of us doing that we have in this where the billing side, we have enough billers to that go around that some are experts in the OP and some in eClinical.

And so the intention is no. Yeah. Where the practices coming in have to make a choice between those two though. Okay. 

[00:16:10] Dr. Rogu: How do you like do quality metrics cuz they're different. 

[00:16:14] Dr. Martin: So, yeah, there's, so we do some of, you know, obviously Some's gonna come through the, the billing stuff, but we're actually doing a project called Fortify where, and we're actually part of the Children's Health Network in Northern Virginia as well, where that data's being put as well.

We're building the capacities where this data is gonna be de-identified and pooled. Yeah. And so we'll be able to, to look at as a larger entity, what, what, and as well as what the divisions individually are doing. We have some of that now through the payers, but it's all, it's all payment based.

Right? It's all that which isn't show everything. Right. But we're gonna be sharing actually the clinical side as well. Mm-hmm. 

[00:16:53] Dr. Bravo: What, what motivated you to run the Virginia chapter of the aap? 

[00:16:59] Dr. Martin: My gullibility? Yes. No, no, no. Who, it's funny you ask 

[00:17:04] Dr. Bravo: who threw you in the pool while you were drunk?

[00:17:06] Dr. Martin: Well, all things lead back to Sandy Chung. That's okay. I will tell you in Northern Virginia, all things lead back. So Sandy's definitely in the mix of how I got to be there. It's funny, I will tell you, as a medical student and resident, I did not engage in AAP stuff at all. So when I've gone back and some of my friends from then, they're like, they saw that I was a, you know, the chapter president and they're like, like you, like, cuz they all were really engaged in it. 

And it's funny, I think of my close friends, I think I moved up the highest of all of them in terms of the organization. I think it was, you know, being on the management side and seeing how things, you know, I'm a fixer and I'm just like, this is ridiculous.

Like, why does this happen? You know? I think we've all asked those questions and then we, and a lot of people just go on the way, well, that's the way it is. I'm just, you know, I don't have time. I was like, no, no, no, no, I can't let things go. I was like, I need to, I need to start, I need, I need to figure out a way to, to work on this stuff.

And then, overlapping with that was sort of Sandy bringing me in locally on stuff. Then I became a delegate for the MSV or Medical Society of Virginia, which wasn't a good fit for me.

, it was just the way the organization run. I, I didn't find a home there. And then Sandy had already moved over to the chapter and it's like, you should come check this out, what we're doing. And so I became the Northern Virginia representative and I was like, oh, this is, this is great. I mean, I was just, they, they were working on stuff on payment side.

They had some great immunization projects going. I mean, it was, and the people were just, I connected with, right. So much so. I mean, even, I remember when I started my practice, the person that did a lot of work on the payment side, I had some issues early on and they were able to step in and, and make connections for me and saved me, I'm not exaggerating, at least 30,000, probably closer to $40,000 that I would've lost.

And so I mean, that alone, I was like, I've gotta, oh wow. I have to contribute to an organization that's helped me so much. And so I just felt it was my response. I so much has been given to me, Dr. Schwartz, the chapter, and I just, it was like, it was time to give back for me.

And so, yeah, I just kind of worked up the chain at that point. 

[00:19:20] Dr. Bravo: What, what did, nor what do you think was your biggest win while you were president of the chapter? 

[00:19:26] Dr. Martin: So, when I went in as chapter president, you all recall there was no covid right before I was getting prepped and ready. And then as I was getting closer, COVID came.

So I had this huge agenda, was gonna do. Out the window that went and, and, and I honestly think I'm probably the right person for it. I think looking back, I'm like, I'm pretty flexible. I'll bounce with things and that was covid for two years, right? Yeah. Adjusting, making constant pivots and adjustments.

And I'm a pretty open person to change and hearing different perspectives even when I go into a pretty hard stance. I think for me was just doing that pivoting and, and at each step identifying the needs for the pediatricians in Virginia. I mean, the earliest thing I remember doing is we like getting masks, you know, get, getting just face masks, getting supplies that were, that people couldn't get.

And we, I saw someone doing it at a local level. I'm like, why don't we just do this at the state? We kind of had. Five regions I set, you know, started to set things up and take orders from people and started collecting stuff to the point, I couldn't even accept all the stuff. There were, there was a company that was trying to give us, I can't even remember, like three or four truckloads of stuff, but I had nowhere to put it.

Oh, well. So it was a good problem. But I think it was that, I mean, I think for us, each, at each step, something new was occurring and responding to it and really utilizing, effectively communication, multichannel communications with folks. So, you know, we started Listservs at that point, regionally.

 I did some live stuff like this, some podcast type stuff, really. And, and then started, I think we ended up running 30 plus different webinars and things. And really putting those pieces in place. I think all of that was was because of Covid and, and each, as things changed and the needs that were happening, 

[00:21:25] Dr. Bravo: Yeah, you, you did a great job.

I mean, people are very happy with what you did. 

[00:21:29] Dr. Martin: In the middle of it, you're like, oh my God, I hope this is making a difference. Right? You're like, I was probably working 90 hours a week. I was working, you know, Saturday and Sunday was for ketchup. Yeah. 

[00:21:39] Dr. Bravo: No, you did a phenomenal job. E everybody says you did a phenomenal job.

Thank you for that. I, 

[00:21:43] Dr. Martin: I hope it, I, I'm hoping I helped. I mean, I hope I made it a little bit. It was, 

[00:21:47] Dr. Bravo: You also pushed across the goal line Medicaid reimbursement, right? Yeah. You can get to a hundred percent of Medicare, but you got it from 50 to 70. We keep pushing. I 

[00:21:56] Dr. Martin: mean, that, that battle happened before me, and we'll continue. That's been a, a target of the chapter for a long time. And we'll keep, we'll keep pushing. It's, we're not, but why is 

[00:22:05] Dr. Bravo: that? Why is that, why is that important? 

[00:22:07] Dr. Martin: It's one of the huge barriers to providers even taking Medicaid. We don't, I mean, even our region, we don't have, I mean, honestly, across the state, we don't have enough people taking it.

And understandably, the reimbursement so much less. And it's getting harder and harder. Those margins are getting leaner and leaner. So, you know, I see places like, you know, the in Nova Cares clinic that can't run in the clear because they're not being paid for what they do. And while Inova can absorb that, those of us in private practice can't.

[00:22:39] Dr. Bravo: So, we need to make money to pay rent. We need to make money. Our mortgage, we need to make money to treat our staff properly. Yep. And if we don't, you know, if we're losing money, we won't serve anyone. 

[00:22:54] Dr. Martin: No, and we can't hire good people. We can't, I mean, it just tumbles in. You guys probably know this better than, I mean, we're headed towards troubled waters ahead with having enough providers, staff in primary care in general, not just pediatrics, but primary care. And, I mean, we're headed over the ledge. And I'm not sure 

[00:23:14] Dr. Rogu: I know here's my own soapbox on this. What are your thoughts on student loan forgiveness? Because you, as a private physician , your office is not designated as an underserved area, you may be. Servicing a lot of Medicaid and child health plus medically underserved population, yet nobody cares. And across the street could be the Novo Health Center, right? That bought, bought up Dr. Bravo's little practice, and all of a sudden that practice is an underserved area. Or, and then they could get loan forgiveness in that office. 

[00:23:45] Dr. Martin: Yeah. Oh, I think it's, I think it's a great tool and I, you know, when we're doing adv, go back to my chapter hat on the executive board, you know, one of the things that we're constantly seeing is encroachment of scope of practice.

And it's always driven by access. And it's like, this is, this is the kind of tool if you want people to go to a particular area, you know, Southwest Virginia, this is the perfect tool to get people down there. But what we keep doing is giving, you know, non-physicians, Privileges to do other things that n not necessarily trained to do out of that desire for access.

And then they're not going to those regions. Right. That's my favorite part of this. Well, that's, that's second. So box, 

[00:24:33] Dr. Bravo: so that's another, but the, the honest truth is there are many counties in the US that do not have a pediatrician period. Right. And there are very, very many areas even in Northern Virginia where Axis is very limited to a pediatrician.

And I think we are over, I mean, I think we over, over the cliff. This is due change now or we're in, we, we are in deep trouble. Yeah. You 

[00:25:00] Dr. Martin: can't just pull this outta that. The only, the only thing, and this is my fear, is that we're creating the gap's gonna keep getting wider and so you're not gonna have.

Doctors to pull from, they're gonna start giving others the same privileges. 

[00:25:14] Dr. Rogu: I had a discussion, I had a dialogue today with somebody at the P level in the advocacy and basically talking about the underserved areas and medically underserved populations, and , I told them, I said, listen, my office has 20,000 patients, 65, of which 65% Medicaid and child health.

Plus we have like 15, 16 doctors. This year alone. We had four candidates that we could have recruited that came to our office as children. We saw them when they were born, right? Perfect candidates, right? For a great story coming home. They went down the street to a federally qualified health center, or the non-for-profit, literally a half a mile away, servicing the same population of people because they had student loans.

They couldn't come to us for that because of that reason. Now, you know what was amazing to me when they stated to me was, well, Dr. Roku, you seem to be the only one complaining about this. That's weird, right? Well, it's terrible actually. 

[00:26:08] Dr. Bravo: I wanna get away from this means testing. We don't mean test public schooling in America, so we have already a shortage of primary care doctors.

Mm-hmm. Try to see an adult in the chronologist for your type two diabetes. It's a six month wait. Yep. Okay. E even if you have insurance, if you have wanting to pay cash, it's like, Hmm. Can't help you. I, I'm booked for six months. I can only see as an endocrinologist, 10 patients a day, each patients 45 minutes.

Yep. And so let's stop talking about Medicaid. Let's not a chip and this and that. Every child deserves to have a pediatrician in every county. If you go into community pediatrics and you're community based, whether you're employed by. R B K pediatrics, Einstein's Pediatrics, your independent contractor like I am, you know, there should be loan forgiveness because we need access to pediatric care for everybody.

The white kid, the black kid, the brown kid, the yellow kid, the tall kid, the short kid, the gay kid, the heterosexual kid, the boys, the girls, they all deserve. There is no means testing, just like they all deserve primary and high school education. 

[00:27:27] Dr. Rogu: Well, that gets wishful thinking Herb. That's really wishful thinking.

No, you might be able to get, you might be able to get something with Medicaid and child health plus because these are all federally, you know, programs. Right. But you know, I I, I made the, the person realize that my office is located in, it's not an underserved area, it's not a rural area, but if I can hire doctors and the office starts to dwindle and we close the 20,000 patients that we service, 21,000 patients that we have.

All of a sudden we'll have no doctor. And then, you know what, Comac will become a medically underserved area. 

[00:28:01] Dr. Bravo: Right. And then, you know I'm old enough to remember when we didn't get paid for the vaccines and we would do the well child exam and then send the patient to the health department where the nurse would give the vaccine.

And if we do not, if we do not value pediatricians, if we not address their student debt and we don't pay them enough to stay in business, we're gonna go back to the point where children don't get well child exams, they go to the health department, they get vaccinated, and that's all the care they get.

Yeah. And that is not what we want for America. That is not going to produce a strong democracy. It is not going to produce a strong country. So I need all pediatricians to stop talking about Medicaid and start saying, we need to pay paid fairly and we need to be paid fairly today. And every child without means testing needs access to a residency trained pediatrician.

That is what's fair. That's equitable. That's inclusive. Yeah. That's d e i. You know, let's just stop with the nonsense. Yeah. That's really what we should be all saying together. Arms and arms. 

[00:29:18] Dr. Rogu: Yeah. I wishful thinking Herb. 

[00:29:20] Dr. Bravo: Well, George, if we don't dream, it will not 

[00:29:23] Dr. Martin: happen. Yeah, I do think we have to, I think we do have to start being, and I think at the cha at, at not just at, at the national, I think we are attempting to be louder with that message because more falling.

I I will say there's a shift in what, , in practice we're seeing as well. I mean, we're definitely doing more complex things because of the limitations. I mean, in Northern Virginia we've got two hospital systems, two children's hospitals. And like you're saying it, there's a way, I mean, You know, forget can, I mean, can 

[00:29:54] Dr. Bravo: Neur specialties can't, you can't see a neurologist.

Yeah. Psychiatrists in Northern Virginia's two years. Wait. 

[00:29:59] Dr. Martin: Yeah. , there's definitely more incumbent on us as pediatricians for managing than there was when I started. And I just don't, like, I don't see how you do that without more p I mean, it's that workforce has to come from somewhere that has some training in the stuff.

I mean, I, I probably see a quarter to a third of my day is mental health now. Yeah. And that takes some skill. I mean, that's not, you know, I'm starting to get my younger physicians trained to do that. But it takes skill and time and Yeah. It's just blocking our schedules up more as we take on, 

[00:30:29] Dr. Rogu: you know, even with the mental health, you know, the un you, if you're a mental health center or behavioral health center, developmental center, you're qualified for loan forgiveness.

Yes. But Dr. Martin, you're just a pediatrician. That's right. Who cares, right. Nobody cares about Dr. Ro when 

[00:30:47] Dr. Bravo: Dr. Martin. Yep. And then yeah, no, we, we need to change that. Obesity is a big, a big problem. It's very time consuming. It's very important. Yeah. I joke with my radiologist friends that, you know, through most of my career, I never ordered an MRI because if a kid has a weird headache or post con concussion symptoms, I would send them to a neurologist first.

But now no one, they would order the mri, but well, but at least they would know when to and when not to, they order on everybody. But nowadays it's like, I can't get 'em to see the neurologist. So I'll order the M MRI and treat their migraines, you know, with zofran and Motrin until they can get an appointment.

[00:31:33] Dr. Martin: Yeah, no, there's a, there's a lot of that we're doing to patch the time and, and that, and that's where like I'm more and more I'm taking on more complex stuff that I'm like, there is a discomfort with what I'm doing, but I've gotta do what I've gotta, I mean somebody, like, if I don't, then who will? No one will.

That's, that's our, that's our, that's part of our problem sometimes in pediatrics is that we're always wanting to help and we overextend ourselves. I think we're givers. And, and, but you know, that's where I think on the advocacy side, we have to, there are times we have to be like, enough's enough. I'm not doing like, and we, we have to, and we just, I mean, part of this, I do very much strongly feel it has to come not just from us, but from those we serve.

The families and they're the voters and they're the people who have to push back too. That just us, and we're a relatively small group. But we, but I think when everyone starts to feel the pain, we have to educate them on why that's happening. 

[00:32:32] Dr. Bravo: Yes. And so I think at the chapter level, the AAP p has done a phenomenal job of advocating for pediatricians.

[00:32:39] Dr. Martin: Yeah. I'm always amazed how much, I have to tell you a little bit funny story with my nurse practitioner was in the office in the middle of all this covid stuff, and I probably looked 20 years older and sleep deprived. And she's like, ah, Dr. Martin, I hope they pay you a lot of money for doing this.

I just laughed. I was like, she's like, what? I'm like, we don't get paid. We're all volunteers. Right. There's no money. 

[00:33:05] Dr. Bravo: I don't know if there's a communication gap at the, at the Chicago a a p. Yeah. But it really does not feel that they have my back as a practicing pediatrician at the Chicago A A P I Got it.

And I think, I think that needs to be changed because without pediatricians, there are no healthy children. Without healthy children, we don't have a country. You know, so it's like what I tell the mothers in the exam room over and over again, in case of an emergency, put the oxygen mask on your face first, then take care of the child.

Because without a mom, I can't take care of the kid. I'll, I'll tell you, I 

got, 

[00:33:52] Dr. Rogu: and if you think about it, without pediatricians, what will happen next? Yeah. There'll be more aap cuz there'll be no more 

[00:33:59] Dr. Bravo: members. Well there won't be a society because children need to be healthy and cared for. We don't want them just to get shots at the health department from a nurse.

That can't do developmental screening, that can't address their mental health needs. But what are your thoughts? Yeah, 

[00:34:17] Dr. Martin: so I, I have to tell you, so this, I, they've gotten this, I got it at the chapter too, where people didn't feel we represented them. This was a few, I I feel like we're in a better place now, but there's, you still get some of that.

I think we made some inroads in it, and I, I get the same, the disconnect that pediatricians feel with the national organization. That happens, I think for the chapter. I will definitely say, and I think national is a victim of this. I think sometimes there's not enough communication to let you know what's being done.

There's a lot of things done behind closed doors and being like, when we were doing advocacy stuff, I don't think people knew and that, that when I joined the board, I do remember, and that was a real push for us to start. Being better about how we communicate and really pushing that out and engaging folks in discussions about what they wanted us to do.

And so I do think of the chapter, we made a very mindful effort, and I think Covid helped even accelerate that. I think there are efforts at national and recognition of that disconnect because I do think there's a, I mean, I like a lot of these people you've had on here to interview, there's amazing people, they're amazing on our behalf that are doing stuff that I think the majority of people don't even know they're doing.

[00:35:32] Dr. Bravo: Right, right, right. Their story needs to 

[00:35:35] Dr. Martin: be told. Their story needs to be told. Yes. And I, and I think figuring out how to best do that I just, I always say like, I just, in medicine, this was one of the things we're always behind like 15 years of business practices, you know, in terms of how we run our practices.

Yeah. Like, it's really fascinating to see, but I think that carries over to some of our organizational stuff too. Yes. There's that. They, it runs a little bit like an organization did 10, 15 years ago. Well, what? No, the 

[00:36:04] Dr. Bravo: AAP runs like more than that. 15 years. I'm being nice. 

[00:36:07] Dr. Martin: Work with you. People 

[00:36:09] Dr. Bravo: don't, so, so 

[00:36:10] Dr. Rogu: you, you got and clack over here.

Two knucklehead doctors that figured out how to elevate pediatricians. Very difficult. 

[00:36:17] Dr. Bravo: With a zero budget. With a zero budget. With zero budget. With a zero budget. No, but, but here, here, I don't think the AAP has realized yet that monkey survey can survey 60,000 people with one button. And you can, you can, you can ignore.

 The feedback, right? I mean, say the obesity guidelines, right? You could have put it out to the 60,000 pediatricians for a review and given them 48 hours to look at it. And on a survey monkey say, you think this is doable at your, at your, wherever you are, you know, like private practice, hospital, academia, and, you know, gotten a report back, you might choose to re ignore the report, but now people felt heard.

Yeah, right. And, and it's monkey survey, it's $230 a year 

[00:37:11] Dr. Martin: for 10,000. And, and there's, there were a lot of different ways, right? You could have, I've seen organizations where they, you know, there's all these conferences across states and stuff where this stuff could have been presented there.

Here are some of the things we're working on, right. Looking for, I mean, there's different ways one could do that, but could do. But, but I'm just 

[00:37:28] Dr. Bravo: saying you wanna do a cheap, you wanna reach everybody. It's called Monkey Survey. Yeah. And that's been around for years. Yep. No, I get you. Right. Yep. So, so I think that's where you feel that disconnect.

Like I don't know who they are, I don't even know who the board members are. You know, I 

[00:37:45] Dr. Martin: mean, I don't find, I think it's, I think it's interesting what you're saying because I think in a lot of ways they did it the other way. They put a lot of time once it was out and getting and discussing what it meant, right?

Yes. And telling you why they did what they did. Making it a little more transparent on the formation part, things working on including, it's, it's a different model. It's a d I mean it's, it's the 

all 

[00:38:08] Dr. Bravo: model. And, and I, I totally understand it cuz I grew up in the time that if you wanted to go read a journal, you had to be affiliated with a medical center and go to the medical, you know, the, the medical library, the big hospital.

Yeah. And they had all the journals and you know, they could pull 'em out and you photocopy it and you're taken home. We don't need that anymore. Yeah, we don't need a huge library in Chicago. Yep. With all the textbooks. And it's called up to date. It's called Google, it's called Bing. And you know, for 15, $25 I can download any, met, plus any article I want, read it and figure it out.

So we, we are no longer bastians of Waldo knowledge that we used to be before the internet came. And the internet came before 2000. 

[00:39:00] Dr. Martin: Oh, forget Internet's old. It's chat g b t Now you just tell chat TBT what you want and it'll pull it for you. 

[00:39:06] Dr. Bravo: Yeah. George loves chat. G B T i I think is such me. It works. It does.

There is, there is going to be a place where Ja chap GBT four, not three in healthcare and some people are already working on that. It's called Carbon, for example. Mm-hmm. And they, they really will create your note from listening into what you're doing. 

[00:39:31] Dr. Martin: A hundred percent. That's the direction. It's so great.

We're doing, we're database entry right now. Yes. Yeah, we're 

[00:39:37] Dr. Bravo: right. It doesn't make any sense at the cla Oh, talk about poor management. Right. You, you get the person that makes the most income for the. For the company, the most revenue, the most highly trained, and your tournament to a date Andrew Clerk.

Right. 

[00:39:55] Dr. Martin: Yeah. No, it, it genius. It never 

[00:39:57] Dr. Bravo: made sense. That was genius. Yeah. That was genius. This is genius. And I'm not gonna say who, who did that to us because I get in trouble, but that was a genius idea. 

[00:40:07] Dr. Martin: I look at it, it's gonna be a very small piece of history, and it really was just, it's gonna be a very sh I mean, I, I knew it would be this direct.

I knew this was a temporary thing and I, this is the technology that's gonna, I mean, the people who need to be worried are actually, and I'm happy because they drive me nuts. It's the EHR companies. Yeah. They wanted, they wanted to like charge us for this and that. And the AI is gonna take a lot of what they do away from them.

They're not, you're not gonna need. Right. 

[00:40:36] Dr. Bravo: Yeah. Well, 

[00:40:37] Dr. Rogu: I'm using chat g bt within my EHR where. I tell it, write me a history of an illness for a child with a sore throat. It writes me some words, a paragraph. I fix it up a little bit cuz it's never good. And then I drop it into these phrase construction places and I talk to the patient.

I know what I'm gonna ask. Whoop, put that button. I got a paragraph. Yeah, no, you even used it. I've even used it on some rebuttal letters for insurance negotiations. You know, when I was big on the covid testing. Mm-hmm. And I went into chat. Bt I said, write me a rebuttal letter to the Evil Empire about not covering covid testing or whatever.

Oh my God. You want to cry after that? How could you not cover covid testing in little poor children? 

[00:41:23] Dr. Bravo: Yep. Yep. So, Mike, Mike, what challenges do you still think that we face as a, as a profession right now? What, like top of the line? 

[00:41:33] Dr. Martin: There's a long list. I hate to say it that way. I wanna start by saying I still love what I do.

I think it's an amazing thing that we do. You still love what we do? Yeah. I mean, I still love it. Cuz that's where I look at, I look, you know, I'm sort of at that middle age, right, where everyone starts to question and they get their sports car and they question their decisions they've made. I have no doubts that pediatrics was the right decision and, and I'm grateful for it.

Every day I go to work. You're a rockstar. No. It's just a fun field. Where else can you go in? You smile the kids. Yeah. I mean it's just, it's a happy place. Yeah, definitely. We got the best job in the world. It brings joy and it's, important. That's the other thing I always, this is the conversation I always have with my wife.

Cause it, it's like she can make so much more money than me. But I'm, I'm like, I'm doing more important work.

You're, you're not gonna show this to her, right? No, 

[00:42:25] Dr. Bravo: I, I would not say that to my wife. 

[00:42:28] Dr. Martin: So challenges I think the insurance piece is just always, is the big bear in the room. And, the margins are getting tighter and we have to, you know, you can only run things ever somewhat more efficiently.

And so I, that has not been fixed by anything. And so I still think on the payment side is still one of the biggest things for us is getting recognition for what we do. I look at other countries the dollars they put into primary care, whereas our country inverts it and puts it into all the specialty care.

Right. And I'm like, and, and one of many reasons why our outcomes aren't as good. Cuz we let there become problems that need fixing rather than prevent problems. But unfortunately in the models, you know, and this is where I think the AP is definitely doing work, is looking at guides as to what's important and what should be rewarded in the payment system that's gonna lead to good outcomes for kids.

And, and that's always, that's the challenge is the insurance company looks two years ahead, we need to be looking 30 to 40 20. Yeah. Right. And so that to me is really where a lot of change is happening. And, and I think we're making headway in getting them at the table and having pediatricians decide what those should be.

But still a lot of challenges with that. 

[00:43:58] Dr. Bravo: I think you're right. I think the, the financing of healthcare where we cheat the kids and we underinvest in their health and their wellbeing is really costing us a tremendous amount. Yep. So Kaiser Permanente has a study that says the average Medicaid child spends $2,000 a year while the elderly is spending 13 to $15,000 a year on Medicaid.

Right. And, but, but all the time we hear well, You, you had this many preventable ER visits and you had this many preventable hospitalizations, and you wrote for this brand name only here that cost this much money. Are you kidding me? Each kid's costing $2,000 a year. How much leaner do you think we can get?

And 

[00:44:47] Dr. Martin: I have to tell you, it's, yeah, it's crazy. We have, one of our payers is wanting to decrease us 8% and with inflation, our cost going up, they wanna decrease what they're paying us 8%. How is that a good idea that, that I'm like, and I'm just like, that's exactly it. I'm like, how many, how, how much are you gonna, how much more are you gonna squeeze out of.

[00:45:10] Dr. Bravo: You, you know where that's coming. I don't think you Nova's doing this, but you know where they, they are doing it in Long Island, you know where that's coming is you, you check into the ER today, you get the multi respiratory panel screen. Yeah. That's 50 12, $1,200. So they, you know, that's going out of their margin.

So they're looking for, you know, someone to take a haircut. Yeah. And the pediatricians are the easy haircut because you're not gonna 

[00:45:36] Dr. Rogu: complain. You're gonna 

[00:45:37] Dr. Martin: say, thank you, give me, well, and so that's, that's the message. Yes. You have to complain and, and you have to, and this is where it's hard, but going toe to toe and saying, we're not gonna take your insurance, then Yes.

Well, that's not the, that's the only, that's the only leverage you have. 

[00:45:50] Dr. Bravo: Georgia, I think sometimes it, it is like there's some managed care Medicaid plans that pay, you know, like 50% of what regular Medicaid pays and people still take them. They don't even know they're taking them. You know that, so no.

Okay. I'm not gonna take that because this other managed care Medicaid is paying me two times as much as you are paying me for the same work. Sorry. Yeah. And those patients will switch over to the, to the other Medicaid 

[00:46:22] Dr. Rogu: plan. Well, that power, you do have to, to the, to guide them into a different plan. You can call the ones that Yeah, of course.

Paid more to come in for their routine checkups. And ultimately this company will have poor HEDIS measures and they'll have poor reports and poor quality and so forth and so on. Yeah. And those guys usually don't care about pediatrics. That's why they do that. 

[00:46:43] Dr. Bravo: Well then fine, then, you know, then 

[00:46:46] Dr. Rogu: they have to have it, they have to have a pediatric 

[00:46:48] Dr. Bravo: presence.

Yeah. But if people put their, their big boy's pants on or skirts or whatever, they put on, you know, below the waist, then they tighten their belt and they go, I'm not gonna put up with it. And 90% of the pediatrician in Virginia will not take plan number X. Because of unfair reimbursement practices. Guess what?

Things will change. Well, that's where the problem comes in with, but, but if it went and we don't do anything, we can't do 

[00:47:11] Dr. Rogu: that because of 

[00:47:12] Dr. Bravo: regulations. There is no regulation. You're, 

[00:47:15] Dr. Rogu: you're, you're unionizing doctors, you're mobilizing doctors, you're organizing doctors against the company. No. 

[00:47:21] Dr. Bravo: Yes, it's a problem.

It's not a problem to say Medicare fee schedule is a hundred dollars for 99. Two 13, say, I don't know what it is right now, but say if a payer gives you less than, you know, less than 50% for 99, 2 13 compared to Medicare, then you should not participate in that plan. There's nothing illegal about that. 

[00:47:44] Dr. Rogu: No, there's nothing illegal about that.

What the illegality is. You convincing Dr. Martin myself, correct. 

[00:47:50] Dr. Bravo: To not, okay. Well that's different if I what you talking specifically about the evil empire? Yeah. And you know, and to, just to the two of you in a closed room when we were all within a three mile radios and we all agreed to dump the evil empire in the same week.

Yes. But to educate pediatricians to say if someone's paying you 50% of Medicare, you cannot make money. Drop that plan. Yeah. You can't drop that plan. Do to do the community a service, drop the plan because that will send the strong message and the people will move over general, the insurance company or they will change their ways cuz they need access to pediatricians.

Yes. But 

what 

[00:48:36] Dr. Martin: I do think strongly that's the answer. And I agree. Like we can't all get in a room and, and discuss this stuff. But if we all, as a general rule, are not letting. Ourselves. Take, let plans take advantage of us. It, it's gonna disseminate, right? I mean it's, yeah. Most people doing this and you know, I think at the end of the day, it's like, the truth is like, we're in areas where there's not enough pediatricians and you do that they're gonna have to deal with us.

Yes. Cause there's not enough of us. 

[00:49:07] Dr. Rogu: Hey, if that happens, it'll become a medically underserved area, then you can get your loan forgiveness 

[00:49:12] Dr. Bravo: True. 

[00:49:13] Dr. Martin: And, and we all get what we want. See, I knew we could everyone, 

[00:49:19] Dr. Bravo: so I'm always happy when he, it was a good episode. I like being, I like being grumpy and cynical and then I hear your laughter and I'm like, well, well, that could be better.

[00:49:30] Dr. Martin: But I mean, this is, I mean, this is all really important stuff and, I think this is, As individuals, our voice doesn't carry as much. Certainly say no to insurance plan, but this is the stuff that the aep, we need them for. Right? And we have to have, like, we, we need someone sitting at the big boys table with the big plans and the leadership in those plans and having these discussions like this doesn't make sense.

This has to change. 

[00:49:56] Dr. Bravo: And, and we do need a union and it's not illegal to unionize as long as you are an employee physician, right? If you're employed, you could be unionized. You just can't be employed in o I mean unionize and be the owner of business. You know, and if the AP doesn't change its communication skills and doesn't have the right leadership, a union's coming.

Cuz more and more physicians are fed up of the working conditions. You know, and the reimbursement. And you know, physicians are very unhappy. They're burning out. And they're quitting mid-career. Yeah. 

[00:50:32] Dr. Martin: Now that's been, I will say having gone through covid, but pre-post that's been the scariest thing for me is just seeing the overall morale. Yeah. It's really down. Yeah. The morale 

[00:50:44] Dr. Rogu: is down. The applicants are down. Heck, we're using three headhunter corporations and we can't locate a candidate. Yeah. Three, it's not like you're calling residency programs. 

[00:50:55] Dr. Bravo: Yeah. No. It's, it's a shortage is here. A shortage is here. Oh, yeah. And it's, 

[00:51:00] Dr. Martin: yeah. It's, I mean, that's the thing.

It's already here, but it's gonna get worse. And that's like, you're not seeing mobilization and you're kind of like 

yes. 

[00:51:07] Dr. Bravo: Yes. And you know what's worse is that I'm a little bit older than you. Yeah. Like about, about a decade. And so I'm more likely to start getting sick and needing an internist. Yeah.

And there's none of them. Yeah. There's no, you can't find an internist. They're all working. 

[00:51:23] Dr. Martin: It's, it's, no, it's hard. And it's, they're all 

[00:51:25] Dr. Bravo: work at 12 hour shifts at the hospital for three 50. And they're on a week off. A week on a week. And they love their lives. 

[00:51:34] Dr. Rogu: No, they don't. Well I have a lot of friends at hospitals.

They don't love their lives. 

[00:51:38] Dr. Bravo: Well, it's better than the intern is, you know, that's not making any money and seeing all these complex patients. Yeah. You know, in a little, you know, two person office and is swatting how they're gonna pay for, you know, their staff this week. 

Well, I don't want that for the kids. That's gonna happen. No, it's not. You're now you're being like, you know who, 

[00:52:02] Dr. Rogu: well, you know what? I am starting to get drained. You know, our line was primary care when you wanted urgent care when you need it. Services provided by physicians.

Great line, right? Yep. Great practice. Because we're having this crunch I gave in and it killed me to hiring Nmps. But you didn't have anybody yet. We didn't do it, but we're starting 

[00:52:25] Dr. Bravo: to look. But Dean, you didn't find the candidates that you were, that you thought you were comfortable with? Well, they all went to the, the system.

Okay. Well, no, I'm the nurse practitioners. None of 'em were experienced. Oh, no. Those 

[00:52:37] Dr. Rogu: guys, they were, none of them were experienced. They were fresh grads. I, I'm gonna have a 22 year old taking care of a meningitis or something. No, thank you. 

[00:52:45] Dr. Bravo: And so, but what I think the future payment has to be addressed.

Our, the way we are treated as human beings has to be changed. That has to be front and center at the A A P in Chicago. It has been front and center at the A A P at the state level, but not at the A A P in Chicago. We need a leader that will put that front and center cuz the shortage is here, the crisis is now and the change needs to happen now.

But I do think, cuz I'm an optimistic after two bourbons that 

[00:53:20] Dr. Martin: Where's mine? I didn't see. 

[00:53:22] Dr. Bravo: I know, I'm still, I'm still in, I'm still in Brian's office. I can't take, I think office. We 

[00:53:27] Dr. Rogu: gotta get, I think we gotta get Dr. Bravo to be the AAP president of Regina. Oh, no, no, no. We gotta get B to be aap, president of New 

[00:53:34] Dr. Bravo: York.

No, my God. No, I'm not, not a good politician. I tell people what I think and in their phase, and that's 

[00:53:41] Dr. Martin: why, so I gotta tell you, I'm the same. I'm pretty direct. I think people in my practice like get the, like I, I cut to the chase. So we have a lobbyist at the chapter. Hugely important, but I had to get a, there was, there was a number of text messages sent to me to keep me preemtively, don't speak, don't, don't say 

[00:54:01] Dr. Bravo: this.

Stick to the talking point. Yeah. But no, I think that as you alluded and I am gonna be political, oh the Obama administration was snickered or Poorly advised into foisting the cash register in front of the, of the American physician. That system was not ready for prime time. It was a waste of money.

But I do think that we're at the brink of where our artificial intelligence, na natural language processing is going to make that system usable and it's gonna make us more efficient. Yeah, and where I see the change coming, which is gonna be difficult for us older physicians is that instead of nurse practitioners and physician assistants, which are also expensive, they gather good salaries.

We're going to move to a more team-based approach where we're gonna have LPNs that are particularly trained in development LPNs that are particularly trained in you know, patient safety. LPNs that are particularly trained in diet and nutrition. Well, this is all nursing work anyway, and they're going to do all that heavy lifting and may, maybe even mental health.

I mean, cognitive behavioral therapy is not rocket science as long as somebody teaches you how to do it and you have the time to do it. And so we might be seeing 50 patients like NOLA is doing in Alabama, but we're not going to be doing the work that is way below our level of, you know, training. So the nurse will go on, she'll, she'll do the weight, she'll tell the parent, the weight's good is not good, the BMI is this, this is nutritious thing.

The other nurse will come in, do the development, the other nurse will come in, do the safety stuff for the kid. When I come into the room, I'm gonna talk about what's important to the parent and what gaps the nurses have identified for me. And then I'll go on to the next 

[00:56:05] Dr. Rogu: route. And then everybody's gonna say, you're not doing nothing, any, everybody else did your job.

[00:56:10] Dr. Bravo: That's the way it works. That's the way the world 

[00:56:12] Dr. Martin: works. I'm envisioning, and this may be unique to my region, that after that goes happen, the patients, the fa, the parents are gonna ask me all the same stuff again. It's quite, 

[00:56:23] Dr. Bravo: it's quite possible. It's quite possible. But, but you know what I mean? If all this, I don't need to score another s a S Q three, a staff 

[00:56:34] Dr. Martin: member can do Oh, I agree with you.

I think the, this, this, these sort of redundant tasks, a hundred percent, but I do think it's, I, at least in the population I serve, I'm like, they're not ready for it either. They, they're gonna have to be brought into it too, because Yes. 

[00:56:49] Dr. Bravo: Well, you know, that's when you go, if you want, if you want me to be doing all this, my concierge fee is three grand.

Right. And that may be let's, and then we know I'll spend an hour with you. You'll see even in Northern Virginia, Where they're driving the huge Escalades that are a hundred thousand dollars. As soon as you say it's three grand per kid, they go like, well, we'll go through their normal process. Thank you. Oh, 

[00:57:12] Dr. Martin: they do.

It's like, it's like the after hours calls we do, like in my practice, we do put a fee on it just to cut down the volume. Yes. I had, I had a, I had a mob call 20 times in two months after hours and never, never came in for a visit. Just used it as a yes. 

[00:57:32] Dr. Bravo: This is ridiculous. What else have, what else have, do you want to share with the national audience that I haven't asked you?

[00:57:40] Dr. Martin: Yeah, I mean, for me it's, you know, we're talking about the things that, the changes you want at national ap. The stuff at the chapter, like I said, there's no money in it. I'm sorry, it's, it's pediatrics. Right. But we, we need people, I mean, and it's, it, it can be small, it can be big. It's, we have. You know, there, if there's things that you're seeing and that you have especially an interest in expertise in, it's like there's a place for you.

And, and I know I'm, I'm doing a lot, you know, working with residents and medical students, kind of bringing them up in that culture. It's like, you need to engage. Like I didn't, when I was at that stage, I, I just didn't understand the value of it Now being out, I'm like, you determine your future and it's, and you can be on the sidelines.

So you can be in the middle of it and making, making, being a part of making the changes. And it's that simple. And I know it feels like at times it's heavy lift. It's, you're not getting heard. But I can tell you, having done this for, I guess it's been 15 years, it, it does make a difference. It's just not as fast as any of us want it to be.

Yeah. But I can tell you when we're not at the table, it goes very badly. Yes, yes. It goes much worse. 

[00:58:53] Dr. Bravo: Absolutely. Well, Mike, it's always nice chatting with you. I'm glad. Thank you. Got time to do this for us. No, this is fun. Yeah, and hopefully you'll be at nnc this, this year, I hope. Yeah, 

[00:59:05] Dr. Martin: it's right in dc.

Yes. Could I, how could I not? It's like I down the road 

[00:59:10] Dr. Bravo: maybe you're like 

[00:59:11] Dr. Martin: well I'll definitely 

[00:59:12] Dr. Bravo: be there, so hopefully we'll get to catch up with you there. Absolutely, absolutely guys. Well thank you for your time. It's this been very entertaining. 

[00:59:20] Dr. Martin: I had a good time too. Thanks a lot for inviting me all.