088 Opening day at my Newly Minted Private Practice. A Young Doctor's Personal Journey from Day #1

Dr. Brian Birch was born and raised in Western Washington. He first came to Idaho while training as a medical student at the University of Washington. He completed his residency at Vanderbilt Children’s Hospital in Nashville, TN, and returned to the Gem State to begin his career.

Dr. Birch has been caring for children in Idaho for over a decade. He is the founder of Treasure Valley Children’s Clinic and is proud to lead the exceptional team meeting the needs of children in our community. When he is not seeing patients or dreaming up his next big clinic project, he can be found running in the foothills, skiing at Bogus, and spending quality time with his children, Elie and Perry, and his wife, Ayla.

Dr. Bryan is part of P.E.D.S and talks about burnout, purpose, mastery, and autonomy to lead change and provide the care that we all want for our children. 

Transcript

Starting A New Practice 

[00:00:00] Dr. Bravo: good morning, George. It's Tuesday morning and we have Dr. Brian Birch with us today. 

[00:00:05] Dr. Rogu: Yeah, today it's another Tuesday, rainy day here in New York. Dr. Brian Birch is a fascinating story because his topic is going to be opening day of my newly minted private practice, a young doctor's personal journey day number one, and we'll check in with him again in a month and six months in a year and see how he's doing.

[00:00:25] Dr. Bravo: So Brian, Brian, welcome to the show. 

[00:00:29] Dr. Birch: Thank you guys. It's great to be here.

[00:00:32] Dr. Bravo: Brian, why, did you become a pediatrician? 

[00:00:34] Dr. Birch: I would probably say fame and fortune. So and I joke, but I think part of that was actually true. So I remember as a little child going and seeing my pediatrician where I grew up in the Pacific Northwest Dr. Gregoris. And I would say outside of my immediate family to influential people in my life that I looked up to were my pediatrician and my pastor. I remember telling my parents one day that I wanted to become a pastor and they went and went to my pastor and they're like, Oh, did you hear, you know, I was probably seven years old at the time.

And they said, do you, did you hear Brian said he wants to become a pastor. And my pastor was so proud and this is great. You know, we'll get you into the ministry. We'll nurture that and culture it, I'd ask my, my parents, Oh, what does, you know, what does a pastor make?

Because I was just starting to learn about money at that point. And they're like, Oh, probably about the same as your dad makes. My father was a maintenance carpenter at Boeing. And so probably about the same that your dad makes. And I said, okay, great. And about A month later, I found out that the pastor didn't just work on sundays.

 The next person down the line, which was my pediatrician. And my pediatrician was a old school pediatrician. He worked in a, in a two provider office. I saw him frequently for, you know, my well child checks. and for I had frequent ear infections and some speech delay when I was younger and so saw him for those issues.

And, you know, that memory of my pediatrician kind of always always was there. And as a, as a child, you know, it really was, you know, fame and fortune. I think as I got older You know, what really drove me into pediatrics was I really liked kids. I liked caring for kids. I liked their parents as well which is a good mix because you have to like the kids and their parents.

But ultimately, I had volunteered for a number of years at a camp for children with HIV. And it was a family camp, and a mentor of mine was a pediatric infectious disease doctor. And I really loved... Interacting with kids, interacting with their families, and initially thought I would go into peds ID and do kind of h i v work.

Realized partway through the journey, while an A type personality I'm not as most infectious disease doctors. A plus personality. So I went ahead and stuck with general pediatrics. And here I am now. 

[00:03:05] Dr. Rogu: Well, you do have the most popular job in the world. You're like a rock star and you are famous. Now in private practice, you'll become even more famous. 

[00:03:14] Dr. Bravo: your first job with the health system in Idaho? Did you go? 

[00:03:17] Dr. Birch: Yeah. So I did residency at Vanderbilt university in Nashville. My experiences through the University of Washington kind of primary care medical school program was rural medicine.

I really love the idea of rural medicine. I did rotations all around what's known as the Whammy area, the Washington, Wyoming, Alaska, Montana, and Idaho. Regions that the University of Washington serves, and I had the opportunity to go back to Twin Falls, Idaho where the area that my wife had grown up and started out, I was able to do everything. I was impatient for admissions, I was in the NICU for stabilizing critical critically sick infants and premature babies taking care of 32 weeks and above in our kind of step down NICU as well as doing outpatient pediatrics. So started off straight into a large healthcare system.

[00:04:10] Dr. Bravo: There's a lot of confusion on terms, like people talk about burnout and then people talk about moral injury. Some people think that's the same. Some people think that they're different. To me, I think there's something called repetitive stress injury, which is when you do the same thing over and over 10, 15 times in a day, and there is no change. I think , just like the kid that only plays baseball ends up with an elbow injury. And then there is the moral injury side of it is when you know what you need to do. And you can't affect the change. Did you come across either one of those through your 10 years in the, in the health system?

[00:04:53] Dr. Birch: Yeah, absolutely. I would also say that there's probably a difference between professional burnout and then. Personal burnout, right. So in my time in the healthcare system, I started doing more administrative work. I started caring more for kids and for, and for providers and was a leader within our healthcare system for pediatrics.

At one point I was the medical director of seven primary care pediatric clinics. And I think you're absolutely right that sort of, there's that repetitive injury. I like to use the definition of insanity is, is doing the same thing over and over again and expecting a different result.

And In administration, in pediatrics, it became like I was running into a brick wall, and it felt like every single time I ran into that brick wall, I was running harder and harder you know, through my time initially in administration, I felt like I was making positive changes in the healthcare system, positive changes for providers, and positive changes for the patients that those providers cared for but ultimately, I started feeling like I was doing more and more I'd like to call defense protecting the kids from decisions that were being made rather than playing offense, which was trying to make improvements in the care that we are already providing.

 That ultimately led to my burnout within administration and leadership work was not feeling like I was making that progress within the healthcare system. 

[00:06:22] Dr. Rogu: I think the health care systems, they patronize pediatricians. They humor them. You're, you're a cutesy guy, you can tell us some stuff, but if you want big changes, you don't matter.

They're just pediatrics. Go play in the sandbox. 

[00:06:37] Dr. Birch: Yeah. I once had a chief executive tell me he forgets about the kids sometimes. And he said that in the most sincere way of we need other people to help remind us about the kids. But I would respond to that, that we shouldn't only be playing defense.

We shouldn't only be reminding you about the impact that it has on kids. We should also be investing in the future and investing in those kids. Right. 

[00:07:00] Dr. Bravo: The health system in Idaho, is it physician led or is it all suits that lead it, and then they ask the physicians and the nurses for input?

[00:07:09] Dr. Birch: I would say it used to be physician led. So when I first joined the healthcare system you know, it was. It was physicians sitting around a table, making tough decisions because you can't always have your way and then making those tough decisions, walking back to your colleagues and saying, hey, we got what we needed, this is great, or hey, we didn't get what we needed, but here was the reason why, and it was, you know, a tough decision, but ultimately that decision was made, you know by a group of physicians, and then implemented by administration.

That changed a few years ago during a restructure they brought out, an outside consultant hired them who had previously worked at Kaiser in California, and they tried to turn themselves into a Kaiser like healthcare system that was very much top down.

They still have physician leadership within the health care system. But many of those leaders are disconnected from the everyday workings of the providers that they, they lead.

[00:08:12] Dr. Rogu: Well, usually those guys are more senior physicians. And all their experience has been on paper charting. They never even touched a computer yet. They're challenged with making decisions about computers and technology and advanced things. And they depend on other people to tell them what the answer is. 

[00:08:31] Dr. Bravo: So through P.E.D.S Brian, you have shared with us, for example, one of your biggest frustrations, which was the call center and how that limited your patients access to you. Would you share that for our viewers? 

[00:08:44] Dr. Birch: Yeah. My entire time I've been with the healthcare system, we've been on a call center system different iterations of it but have moved more and more towards , across the healthcare system. Essentially, it is a disconnected centralized call center now decentralized in those individuals homes. They're working remotely that take the phone calls and schedule appointments in theory, you think that this would work, it takes the person outside, from the front desk, from having to answer phone calls to being able to serve the patients that are directly in front of them.

In practice what I learned through my administration is actually costs more to do it this way that because you can't have just one person in a small practice up front . But the second thing is, is it disconnects the care of the patient from the provider.

 I think of it kind of like residency. During my resident, or during my medical school training, I went out into rural areas and practiced with providers. And the idea for around doing that was I wanted to have the most experience. There's this totem pole in health care, and that totem pole is one that I wanted to find the shortest totem pole I can between me and the attending physician so I could experience more and learn more.

I think there's a totem pole when it comes to gaining access that the further away that you have the team caring for the patients and the less connected those teams are, the more difficult it becomes to care for patients. So the person answering the call doesn't know Sally and Sally's mom that's calling in.

If you have centralized nurse triage, the nurse that's triaging them, doesn't know Sally and Sally's mom., the basis of team based care and really a medical home is people providing care that are known to and known by the patient. right? So I know the patient and the patient knows me.

In the ideal situation, you want that for your entire staff. They don't, they may not know the intimacies of that, the doctor patient relationship has, but there, there's something to be said about knowing the patient when the patient, when the parent calls in, they know who they're talking to.

[00:10:51] Dr. Bravo: Absolutely. Now we often don't use very kind words towards MBAs and suits at the hospitals. But from their perspective, if I was running a hospital or if I was running Apple, I would focus on the iPhone. The iPhone is my biggest cash cow, has 40 to 50% margins, and I'm going to use that money to reinvest on a better product because it sells well. From the hospital perspective, their cash counts is cancer and joint replacement. That's where their biggest margins are high volume, high margins. And so they're going to invest on those areas, make the area prettier you know, bring more tools for the doctors. Bring, more patients when it comes to pediatrics, when a well child visits 100 bucks, there is no margin for the health system on that. I don't know if your health system was losing money, but our mega health system around here doesn't get into pediatrics, but an internal medicine family 000 per clinician per year. You know, and they look at it as a loss leader because they lock in the referrals for the cancer and for the joint surgeries, right?

So you can understand how it's hard to invest in it, what they call a product that is not making any margins for your system.

[00:12:16] Dr. Rogu: Well, that's the problem right there because medicine is not a product line and all the hospitals that got rid of their pediatric departments ultimately closed down every single one that I've ever encountered. The reason kids are very important and this is the message that we as pediatricians need to instill on administrators that don't know pediatrics is like a seed to a tree to a forest. The kid is born, right? The young parents go to the hospital, they have delivery of the kid, the parents get older, they go to the internist, the child gets older, he gets sick with the nervous parents, they go to the emergency room, the parents, parents, the grandparents get older, they end up going to the internist and got, you know, as things go on and then end up with the hip replacements and they end up with the, you know, the cancers and all the big. Big ticket items, but if you only go after big ticket items, you're never going to do any good business. 

[00:13:09] Dr. Bravo: The problem in Georgia is that you are a long term thinker.

[00:13:12] Dr. Rogu: Yes, that's exactly it. 

[00:13:14] Dr. Bravo: You've been married once, you never getting divorced, you raised two children, you joined one practice, you worked with the practice, you dealt with the old partners that weren't always easy to deal with, and you've always been part of that community. When I'm an MBA at a hospital, I'm just looking for a stepped up. So if I started as director of revenue, I want to look for a job that's vice president of revenue, and then a job that senior vice president and then COO and then CEO, and I'm not going to be there for 30 years, I'm going to be there for a couple of quarters at most. And if I can show the margins increase while I was there, someone will hire me for more money. I'll go there for a year or two and then I'll leave. They're not in a long game. They're constantly dating the new person with more money. , that's what the game is when you're an MBA. It's not a long game. 

[00:14:08] Dr. Birch: I think our healthcare system, I would say, is forward thinking as it relates to population health, risk based care but I think that the problems that I saw was not that people, I mean, it's not that people didn't care about pediatrics, I think they do generally care about pediatrics, but it's, as you said, it's not causing issues right now to the bottom line, so let's not We're not going to focus on that. I think the bigger problem that came down that affects providers in patient care is that those people in administrative, the MBAs, they don't feel the problems. So when we have a centralized call schedule that is messing up the schedule to the point that it is absolute chaos in the clinic that The MBA that's in a building away from the away from the office away from the hospital doesn't feel that they might get a report, but they don't actually feel the chaos.

They don't feel the effect. And so We complain about issues, but that's all they are, complaints, because on the operation side, nobody's fixing the issues. And for me, that was probably my biggest, my biggest issue was that we had issues and people didn't care about fixing the issues because those in charge of fixing the issues didn't feel the effect of the issues.

 Previously when we were a physician-led organization, the physicians around the table were like, I'm feeling this issue. We need to fix this issue. You make a decision that you're gonna fix the issue, and then the issue gets worked on and hopefully gets fixed in the, in the new system the new organizational structure.

The system, have to prioritize it and pediatrics, to your point, are on the low end of the priority about fixing the issues and so ultimately, day in and day out, you suffer with inefficient scheduling, chaotic scheduling you know, I once told an administrator, well, let's have our centralized call center start managing your meeting schedule and they were like, Oh, no, they can't do that.

That would, they would get it wrong. And I'm like, Exactly. Your meeting schedule is this is the equivalent of my patient schedule. 

[00:16:32] Dr. Rogu: But you know what? The one thing that I did learn when I did my MBA program, there was a lecture where you had some physician, physician CEO of a hospital, they give it an example. He would go around to the different departments that he never worked in, and we just ask the people. So tell me, please, what is it about your department? that I don't know about that I really need to know about and help fix. And he would go every month to a different place and he'd find out things. I mean, what do you know about internal medicine?

What do you know about surgery? Nothing, you know, about peds, you know, so that was a, that was eyeopening to me. You have to ask because you tend to be become so. Super specialized in what you do. That's all you do. And another thing I learned about with the hospitals and and all these suits like they have a system that's broken.

Now, is it the system that's inefficient that it's broken? Well, is it just that nobody put enough time into the product? To make the darn thing work. So what they do is some big shot at the hospital has a friend at some other company that says, well, my product is better than that piece of junk you guys are using, and then they bring in a new product.

They did just trash the old one, spend lots of money on a new one. That's probably just as bad because they didn't put any effort into fixing it. So that's the beauty of private practice, Brian. You can put in a system that could work and can't work, and then you can fix it from the inside out. It's that PDSA cycles of quality improvement that you can apply to process improvement, operational improvement, that in the large healthcare systems, we did a project, we're done, we're moving on to the next project, but we're never going back to optimize the previous project.

That's something I'm looking forward to in private practice.

[00:18:14] Dr. Birch: I'm curious. Do you believe deep down in your heart that in private practice, you'll be able to provide better care to your patients compared to 100% when you were in the health system? You would have directly with the top of the food chain.

[00:18:27] Dr. Rogu: 100%. Why is that? 

[00:18:31] Dr. Birch: Because I have control over making those changes that need to be done. You know, there's limitations, right? I mean, with everything you have, there's limitations to what you can do. I can't go and say, I'm going to do. Open up this center where I'm providing free care for everybody because I'm not a nonprofit. I have to create the revenue in order to pay for the products, but I have, I have carte blanc on being able to create the programs and the services that I want under, as long as I can feasibly create a business plan that will support that. And that's where. Within the healthcare system, I presented a number of things that would improve the care of kids that were budget neutral, but because they weren't a priority, were never approved.

I presented things where the healthcare system, if making small changes, could have made significantly more money overall, but it was not a priority to do that, even because it was 10 here and 5 here and you know, 2. 50 here, but when you compound that over the millions of encounters that occur over the course of a year in a large healthcare system, that's real money, but they didn't see the priority of that.

[00:19:55] Dr. Rogu: Do you have any examples for us?

[00:19:57] Dr. Birch: Billing for vaccine vaccinations. Our health care system still continues to bill by injection, not by antigen. And we are a VFc. State that allows us to bill with physician counseling, which All of my pediatric and family medicine doctors that see pediatric age patients do vaccine counseling with every single visit.

This is DTAP that has diphtheria, tetanus, and the pertussis vaccine. It's protecting you from these, you know, diseases you don't want to get. And that one change alone from moving from from one CPT code, which is per injection to the other CPT code, which is per antigen would probably be a couple million dollars in the pockets of the healthcare system for no extra work, but changing the documentation that the physicians are doing to say, I'm actually talking to them about it, which we are and having the coders. Then change how they code it. 

[00:20:56] Dr. Rogu: Well, I guess pediatrics doesn't make any money.

[00:21:00] Dr. Birch: It doesn't make any money when you don't care about it and you don't look at it and you don't look at the revenue cycle management because it's. It's 10 cents here. It's 50 cents there. It's 5 here. It's not the 20, 000 hip replacement that they're going after.

[00:21:16] Dr. Bravo: Right. You can make, if you get 25, 000 from the hip replacement, you got even at a small margin of 10%, you got 2, 500. If you take a 10% of a hundred dollars office visit, that's 10 bucks and they look at it like it's not worth it. It's not worth chasing. Yeah. You know, the, so you've alluded to a lot of the same things a lot of people have said.

[00:21:40] Dr. Birch: Physician led medical practices, hospitals Are much better than non physician led, and it's because the physician still believes in mission first, margin second, they don't believe one exists without the other, but they're likely to do what's right first, and then try to figure out how to not lose their shirt at it.

The, other approach is let's chase the margins, and eventually the quality erodes. And what you have mentioned too, which is what a lot of people do Brian is The inability to make a change. So that's what I call a repetitive injury. You know, where you just do, you know, you keep talking about, we could change this.

 If we have a shortfall, if we just changed the 

way we're coding for vaccines, we make another million that will, you know, that will allow us to improve this or that and no one wants to listen. And that's very hurtful at the end of the day, you know, cause it's like, you're always complaining.

We don't make enough money. I'm telling you how to make more money. And you tell me it's all worth the effort. So, you know, I'm just going in circles and then you can't even help your patients and you can't help the people that report to you. And that is where you really feel terrible. So what is your, what was your vision for this new enterprise?

Because it's not an easy undertaking to go out there and do this. It's pretty brave. 

Yeah, it's 

 mean, it's been a lot of fun. 

You know, my vision is ultimately to provide exceptional care in an exceptional workplace. I want people to show up to work, enjoy what they're doing. Myself included, my staff included. And feel like the their environment is exceptional that in which they get to work, and that will translate into exceptional care, and that's exceptional care for our patients. And so ultimately when we look at our mission, our mission is to help every child live their most fulfilling life possible.

It's not necessarily just about health. Now, we impact health, obviously, but there's a lot of things that impact a child living the most fulfilling life. And this, this comes from my experience of working with medically fragile children highly complex children. They're not going to be, in the traditional sense, healthy, right?

As a lot of people say, we want to, we want to have the healthiest patient population. Well, I'm sorry that the child that was born at 23 weeks who has CP isn't going to be healthy in the traditional sense, but we can still help them live their most fulfilling life and help parents , in that endeavor.

So that's really kind of our mission. And then what we see how we're going about doing that is providing that, that exceptional care at an workplace.

[00:24:26] Dr. Bravo: Wow. That's a, that's a very nice mission. How was your first day? You just opened last week. Yeah. Did you have butterflies in your stomach? Was it an exciting day to go in there?

[00:24:37] Dr. Birch: Oh, it was so exciting. It is one of those things where when you dream of something and then it's finally real it's just, it is so exciting. It's one of those things where we showed up the first day. I mean, we've had good problems as we've opened up, as I like to say. Good problems is. a lot of patients that followed me from my previous employer from the healthcare system over the new practice to the point where we still haven't got them all into our EMR system yet because we're kind of this tweener as it relates to EMR new EMR systems.

We're not quite a startup where you're seeing one or two a day. We're not quite a practice conversion where you do. you convert the data. But it was so exciting that first day just to kind of show up and be like, it's go time. And it's time to, to put everything that we've dreamed about and that we've put on paper into, into, into practice.

[00:25:31] Dr. Bravo: Wow. We shared that, joy. We're very happy for you in that regard. 

[00:25:35] Dr. Rogu: How many people said to you that day, thank you, Dr. Brian, for what you did? 

[00:25:40] Dr. Birch: Oh, everyone. Everyone. Yeah. Yeah. I think I, you know, it was, it was congratulations, you know, or this is so great. And, you know, we're still in the crawl phase of opening up this practice.

Right. So I like to break things up into. Crawl, walk, run. Run is all the dreams that we have that are still yet to be, still yet to come to fruition about how we do things. Crawling is, is providing that basic care that everybody deserves. Walk is saying now we're, now we're doing better than those around us.

And, and running is, we're exceptional and we're, we're working, we're, we want to work that direction

. Yeah, 

 I think you'll be tremendously successful and we're so happy to be part of this journey with you. Now you've shared with, with us and the coaching group two approaches to things that are very sticky.

One of them is ACEs. Because I get frustrated, right? Like you, you need a, what is S S N N N R or not, not an ri. I'm like, that's called a parent. Okay? A stable, nurturing adult relationship is called a parent. Better yet, if you got two parents, aunts, uncles, grandparents, okay. But nobody does ACEs because everybody hits the wall and go like, okay, now I figured out this kid's at risk.

And I, I can't do anything about it. So you have a very novel approach, which I really like. What's your approach? 

Yeah, so I would disagree that you can't do anything about it. I think you have to, there is an approach that you can take. And I think my approach helps this in order to, one, as the pediatrician be able to feel like I am connected with the family.

I think caring is the most important. thing that as a pediatrician, we can provide families. But what we did a learning collaborative a few years ago on ACEs and started screening the parents of the children at their four month visit. Four month visit was a good time because usually the kids are starting to be, you know, starting to sleep a little bit more.

Parents aren't quite as exhausted. And we would, we asked a questionnaire, we had a standardized questionnaire that asks about parental ACEs. And, and the reason why we went after the parents is really this idea, and this comes goes back to the 80s. Dr. Spock, the developmental pediatrician, who in his opening line , you know prologue to his to his book said.

If you you will parent as you were parented, and I would take that one step for further, you will parent as you were parented. That's the default for our parenting skills, unless you are intentional about doing otherwise. And so those parents that have abnormal, or that had aces, that had difficult upbringings, their default May be an ineffective parenting strategy that that may border on abuse that may border on their experiences or their parents experience or their caregivers experiences of drug or alcohol abuse 

you know, being separated through incarceration or divorce. 

The message that I give my families is thank you for sharing this information to me, because I think it's really important for me as your pediatrician to know where you're at with your history , as a child, and therefore your baseline as a. parent as it relates to parenting. Now, what are things that you could do differently than your parents parented you? And then how do we develop a plan? How do you develop a plan to be intentional about doing that differently? And this is a conversation I have for somebody that has an a score who parental a score is eight Or whose parental a score is zero because nobody's is a perfect parent.

And so it's how, how do you want to be different than your parents? And it's particularly helpful because oftentimes , when you have , intact families, two caregivers in the family, they were parented different. And this is something I talk about at the pre, at a prenatal visit is, Hey, talk to your partner about how you were parented the things you liked about what they did.

Talk to your partner about things that you didn't like about how you were parented. And then you come together and say, how can we be intentional? How can I support you to parent in the way that we want to parent? And how can you support me in the way that I want to parent? But that comes from the ACEs screening.

I don't think is a tool that you go, you're not going to fix the parents aces, but you can, you can have that discussion. It's a tool to have the discussion with those that have aces and those that don't have aces in order to have this conversation around issues of aces in situations where there are aces, potentially stopping that generational trauma, that generational aces while even those that don't have aces helping parents 

Well, I love that approach for several. 

[00:31:04] Dr. Bravo: It's very kind. It's very intentional, but it's also it's very motivating, right? We're not focusing on being a victim of whatever happened when you were a child that we can't fix. Or what neighborhood you grew up or what this color, the color of your skin is those I can't change for you, but you are having them turned around and look at the potential future, which is their child and how can we be intentional and change our behavior so that your own child.

Has a better shot into the future, and I really admire that approach is I think it's one that I would like to model myself in practice. It's very beautiful. 

[00:31:47] Dr. Birch: I think the other thing to remember is when it comes to aces, like my children. I mean, unless you consider COVID pandemic and a some people do have zero aces.

That's not true. Being the child of a pediatrician is an ace. Is an ace. And is it a second ace if you're also a small business owner then? Yes. Yes. But I would say though that if my wife and I were to pass away in a car accident next week. My child, my children would have multiple aces, and that's nothing that I can control that a horrific accident like that would happen.

But what I can control as a parent, and what I hope to get up to motivate parents to control is techniques and ways to develop resiliency in their children, regardless of ACEs. Because the data shows that in ACEs, resiliency is, is the most important thing to overcome that ACE. To me, that's regardless of if you have a score of zero or eight.

We need to teach children resiliency. And that's, you know, that's, that's a walk run in my practice that I conceptually have ideas of how we do that. But ultimately, I don't care what the ACE score is. The ACE screening is a tool to then give, to develop a conversation, to show that you care, and then to motivate. parents and adolescents and teens themselves directly to develop the resiliency they need to overcome any ace or future obstacle in life. , that's wonderfully said. Yeah, that's, that's wonderfully said. Then we talked a little bit about another one because this is this is what I call one of these social wars that we're missing the mark on.

We do know that a lot of children die at the hands of gun violence, and it would be nice if we could prevent accidental deaths in pools, cars, planes, guns, whatever, you know, hunting, fishing, wherever. We can prevent an avoidable death in an adult or a child. That is wonderful. You have a very unique approach at asking this because there's another side to that issue, right?

People who are gun owners, for whatever reason, sometimes feel That they don't want to divulge because the government is always trying to snoop on their privacy. But you have a very, you know, whether that's right or not, that's the way they feel. And we should respect it. But you have a very unique way of approaching this with the parents and the kids because you live in a state where hunting is a part of life.

And so probably a lot of people have guns and their grandparents have guns and, you know, their uncles have guns and, you know, at an early age, they go out and they hunt and they fish and that's part of being in a rural community. How do you approach the kids so that you don't alienate the families? 

Yeah, my style of particularly as kids get older of talk is not talking at them, but talking with them, asking them questions, being silly, having fun. So my kind of safety talk really starts off by saying, Hey you know, this is say a four or five year old. Hey, you know, did you drive the car here today? Oh, no, no, no. Oh, did mommy drive the car? Oh, yeah. Yeah. And I'm just, you know, I know mommy's a safe driver, but what do you do to make sure you're safe when you're in the car?

You know, and then we talk about seatbelts and then, oh, do you wear a seatbelt when you ride a bike? Oh, no, no, no. What do you do? Oh, I hold on the handlebar. Oh, do you wear anything on your head? Oh, yeah, yeah, yeah. I wear a helmet or they don't. And we talk about it. Oh, do you wear a helmet when you go swimming?

No, no, no, no, no. I wear floaties. I'm like, Oh, hey, that's good. But even if you're a really good swimmer, you make sure somebody is watching you. And then we talk about swim safety. And then I talked to the kids and I say, Hey, what would you do if you ever found a real gun or something that looks like a real gun?

What would you do? And we let the kids talk a little bit and sometimes it's, oh, I would tell mommy or daddy. Sometimes I would shoot the bad guys. And parents eyes, I've never seen parents eyes get so big when I asked that question. And they hear their child's response because a lot of them don't know what to do.

Then we, I say, okay, yeah, you know what, if you see something that looks like a gun, you don't touch it, nobody touches it. And you go tell an adult. And then I turn to the parents, I say, you know, thing is, as kids get older, they spend time at family members houses.

friends, houses. We can't assume they'd be as responsible as we would be if there were firearms in the household. In Idaho, 60% of households likely have firearms in them. Based upon the best estimates, likely more than that, to be honest with you, 60%. So I say We can't assume they'd be as responsible as you would be because of course you're a responsible parent by keeping them locked up in a gun safe separate from the ammunition.

And then we talk about it and we, and sometimes it's like, Oh, yep. All of our guns are locked up. Everything's safe. Perfect. And sometimes I get responsive. Oh my goodness. Yeah. I have a unsecured firearm in our household. And we talk about ways to get that firearm secured. A lot of families, we've had a mass influx of families over the last five years into the, into Idaho and into the Boise area.

And a lot of families, they're like, Oh my goodness, I never even thought about that because we're not firearm owners. And this rings so true. In my first week of practice in Idaho, one of my partner's families moved from Twin Falls to Idaho Falls. And while unpacking kids were playing upstairs and his patient was accidentally shot by another child with a firearm that was unsecured because of moving.

That obviously taught me from a very early stage, this is absolutely has to be. Has to be discussed. A personal experience. My kids visited my families and my family and my parents and my daughter at four , I think she's three and a half was taking a nap in the guest room and came out and told my my parents, I can't sleep in there.

There's guns underneath the bed. And my uncle had recently passed away, and my father had moved guns, moved his firearms out of his gun safe, put it under the bed to put back into a gun safe that he was ordering, and forgot about them. And so I love your approach. And having that conversation with the adults is imperative.

[00:38:49] Dr. Bravo: I love your approach. I just really do admire that approach. I think it's very, Welcoming. It's probably very effective and nobody feels shamed or put down by your words or your actions. I have no doubt will save somebody's life at some point. So thank you for doing that. I really do admire that.

What would you tell I'm gonna ask you two questions. What would you tell a young person that's going to you enter a health system really coerced because they need the loan repayment about what to be careful when they're contracting with a health system. So if they ever want to leave, they are not stuck there forever.

Yeah. I would say think about worst case scenarios. Think about the end as opposed to the beginning. So, the end is when you terminate your employment with, with the healthcare system. What is that going to look like? Because what we know is most, most providers will change jobs at some point in their career.

Your first job is unlikely, unlike George, to be the place you end up. Your entire career. So think about the end. And what would separation look like? And what restrictions are there on your separation? So I am fortunate that the health care system that I worked for did not have a non compete. I only had to give a three month notification that I was and I could, I could, I could have set up shop right next door and said, come here instead sign out front.

And yeah. There wasn't any non compete there, and I think, and my hope is with some recent FTC changes and non competes that that will be standard practice for physicians across the country. I know that the hospital associations are fighting that and trying to exclude physicians from non from that non compete.

Outlaw non competes. The second thing I would say is, you know, thinking about insurance, tail insurance you know, that can be pretty costly. And, you know, so you may, they may provide your malpractice insurance for when you are practicing with them, but how are you going to pay your malpractice when you leave for insurance that, or for, for care that you provide while you work the health system?

Is that your responsibility to purchase a tail? Is it the health care system that's going to purchase the tail? And then I think the three, the third thing is, is make sure you understand from the beginning what you're getting into. Where, what things can you control? And what things can you not control?

And are you okay with that? I've learned through this process of starting to practice really the ideals of the serenity prayer of, you know understanding, what you can control. Give up and don't worry about the things you can't control and have the wisdom to know the difference.

 I wasn't okay with giving up control of things that I felt impacted patient care. Chip Hart gave a talk last year around this idea , there's three things when you take money off the board that really bring fulfillment in a career. And this is regardless of medicine or not medicine and it comes down to three things.

It comes down to autonomy. Mastery and purpose. I think as pediatricians, we all have a purpose. You know, that's your first question when any guest gets on your show. Why did you become a pediatrician? Autonomy, I think. We see a lot of people losing that in large health care systems. I would also say part of my, whether you want to call it moral injury or burnout, was the fact that my lack of autonomy, impacted my mastery.

I wasn't able to care for the patients in the way that I thought I could and I ought to because I lacked the autonomy to make those decisions that impacted the care of my my patients. And so while I still had a purpose, and I would say a very strong purpose because I love being a pediatrician.

I love caring for kids. I found that I was lacking the mastery that I could have had. Because the systems around me didn't support. where I wanted to be and I didn't have the autonomy to change those systems. Now as an independent practice owner, sky's the limit. I have the autonomy. Have the autonomy to make the changes that I want in order to have the mastery.

Of my craft of pediatric care very well. Of course, that purpose is still there. 

[00:43:41] Dr. Rogu: Very well said. I'm curious to see the day that you went to your CEO, whoever your superior was. And you said, I am planning on leaving in three months. How did that conversation go? And what did they do? 

I sent an email. Really? 

[00:43:57] Dr. Birch: I signed my contract for my building lease and then I sent an email and I said, I wanted it to be documented that exactly three months from now I'm leaving. Now this, I don't think anybody was surprised that I was because we had numerous conversations months and years preceding my leaving . things needed to change on a number of different levels. I've never been one to threaten. I say what I have to say, and if it's not going to work out, then I'm going to do something about it. And doing something about it either is I'm going to suck it up and I'll live with, the fact that things aren't going to change, or I'm going to do something about it, and I'm going to change myself.

So I left Twin Falls. About five years ago, and I was technically in a professional service agreement arrangement, so a PSA agreement with the health care system, but essentially I was employed in the health care system. And I at that time had said, Hey, I'm really getting burned out on inpatient work.

I'm doing a lot of administrative work. I love doing this, but I can't be a father and a good spouse. Wow. All this work, and I think we need to move in the direction of hiring hospitalists for inpatient work, and that could offload some of us that want to step out of the inpatient side.

At that point, we'd already been forced out of the NICU. So it's just, taking the 

[00:45:28] Dr. Birch: middle of the night admissions. And my group said, No, that's not where we're at right now. We don't want to do that. And so Six months later, I said, I'm leaving. And they said, where are you going? And I said, I don't know, but I wanted you to be the first ones to know.

And they were like, why? And I'm like, we've talked about it. They're like, yeah, we understand. Of course, a year and a half later, they hired hospitalists and got out of the hospital stuff. So but I've never been one to say, do this or else do this or else. I say, here's the problem. I want you to fix it.

If it's not a priority to you, if it's not worth it to you, I'm not going to waste my time trying to convince you or threaten you to change. That's not the relationship I want to have with an employer. That's not a relationship I want to have with anybody that I have to threaten you to change. So my cards have always been on the table that I wanted things to change things needed to change.

And we got to the point where things didn't change. And so I said, all right, I'm moving on. 

[00:46:32] Dr. Rogu: You know, you're the kind of a physician that Any CEO with half a brain, when they had the conversation with you that you want to leave, should do anything possible to make you not leave. To make you happy. 

Are you kidding me? 

[00:46:49] Dr. Bravo: He's exactly the physician I don't want. He's got values. He's gonna do what's right for the patient. I don't want people who are not thinking. They'll just do what I tell them to do. Punch where I needed to punch a click on the EMR and keep making the money. I need them to make and not cause any more problems for me to address.

They don't want people like him in the health system. They want automaton. So they could replace us all with AI. They would tomorrow. So they don't have to deal with the human element. 

[00:47:21] Dr. Rogu: I was thinking of it from the private practice point of view. I would do everything in my power to keep you. I agree, but not from the mega health system.

That's he's just being a pain in my rear end. That's my point. Absolutely. 

[00:47:37] Dr. Birch: So there's a difference between being a pain in the rear end because you're high maintenance and a pain in the rear end because you feel like you and the healthcare system should and could be better. And. Unfortunately, they don't have Me there and others, I think, like me, that will help them be better.

[00:48:05] Dr. Bravo: Yeah, and they'll leave. The people that are like you there will leave. Well, I mean, around here, and I'm sorry to say this, but we make fun of the Kaiser doctors. The Kaiser doctors are not the best doctors around here. I know it's different in California, but in Northern Virginia, Kaiser doesn't have the hospitals and the integration.

So people that go to the, to the Kaiser system. They might care a lot, but they like to come in at 10 and leave in three and not worry about anything else. You know, that's just it's pretty much the government employee model. You know, and but I learned this very early on in the health system.

When we started a pediatric emergency room in a community hospital, I asked for a fax machine. So we could fax the note when the patient left to the primary care doctor so they could have it, so they could follow up. And I was talking to the chief operating officer, back then, granted fax machines were like 700, they weren't as cheap as they are today. If anybody even has a fax machine anymore. I was sitting in his office and he said, Herb, I would love to help you, but you know what the problem is? The orthopedic surgeons bring in more money than you do. And if I start doing favors for doctors, then they're gonna want a plasma TV in the in the surgical lounge.

And that's gonna cost me 5, 000. So I'm gonna put it in the budget and press really hard to get it for you next year. That's how they think. You know, , it's a small cost and it would make a big difference in care and for, you know, the pediatricians and for the patients. And it's better practice that they don't care to them. It's an expense and other people that break more money to the system. One asked me for bigger stuff cause they, they, they can demand it. Brian, what advice would you give to people who are getting ready to start their own practice that you've already noticed would have helped you transition faster or easier?

[00:50:06] Dr. Birch: I would say, dream big you know, whenever you build something, you have to build it twice you have the dream, and then you have the do so dream big, and then as you get closer, Make sure as you go to implement that it's doable, at least. Think about it in the crawl, walk, run method. You don't want to kill the big dreams because that's what's gonna motivate you. That's, that's gonna, is what's gonna get you up in the morning, , going to work and grinding and hustling at the start is that, is those big dreams.

Our natural inclination is to focus on the on the run on the big dreams and sometimes forget about the basics and the basics are hiring good staff, finding a location that's the long that's the most difficult thing is finding space that's not going to break the bank, hiring good staff, understanding.

Revenue cycle management so that what the work you're doing, you'll get paid for and then ultimately providing good care. That's kind of, that's that crawl and then you'll, you'll grow from there. 

[00:51:16] Dr. Bravo: I have no doubt you'll be, you're going to be tremendously successful. You know, and so, well, thank you for the time you're spending with us.

[00:51:24] Dr. Birch: I know time's tight. Thank you, Brian. Thank you guys. But we'll follow along with the journey and you know, we'll check in with you in six months. Absolutely. All right. Take care, Brian. Happy 4th of July.