Discussing the possibilities and future at the intersection of healthcare and commercial real estate
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Trisha’s guest this week is Daniel Lieberman, MD. He is the medical director of Phoenix Spine and Joint, a multidisciplinary spine and orthopedic surgery practice with three surgery centers located throughout the Phoenix area (with a fourth one on the way). Dr. Lieberman shares how he started and grew his practice, and how he serves his patients with minimally invasive procedures.
[2:11] The background of Phoenix Spine and Joint
Dr. Lieberman was a neurosurgeon, and he had to give up surgery when he developed essential tremor. Phoenix Spine and Joint was his practice. He grew up in Phoenix, and when he came back to practice medicine he was at Good Sam. After about three years, he had the opportunity to buy a hospital along with twelve other surgeons. They operated there together for five years and then sold it, and it worked out really well for them.
After that, Dr. Lieberman opened a surgery center. He decided to do outpatient surgery from that point forward, and over time his one surgery center turned into two and then three. So he now owns three surgery centers, and he no longer operates. So it has been quite a roller coaster experience from private practice to hospital company to surgery centers.
[3:49] What drew Dr. Lieberman to neurosurgery
When he was in medical school, Dr. Lieberman really saw himself as a surgeon. Then the decision came down to where he wanted to specialize. He didn’t want to be a general surgeon, and he really loved neuroscience and the brain, specifically. He did not know a lot about spine surgery, so he thought he wanted to focus on being a brain surgeon.
[4:33] Dr. Lieberman’s decision to open his own private practice
He went to what many people would rank as the number one training program in America for neurosurgery, the University of California at San Francisco. Ninety-nine percent of the people go into academic practice. As Dr. Lieberman was getting out of school, however, this area seemed kind of bankrupt. There were a lot of neuroscience PhDs, and he thought that the neuroscience that surgeons were going to do would be chump change compared to what the legions of PhDs would be doing. He looked around at the procedures he was doing and virtually everything came from a company rather than from a lab. He decided to pursue a different path, and he went into private practice.
[5:34] Growing a patient-centric medical practice
The practice started out small, and he was able to manage the practice around the patient experience. He thought about what they did and how they should manage things. For a long time, he thought he wanted to have a focused “factory for surgery”. The products were laminectomy, microdiscectomy, spine fusion, and ACDF. At some point he realized that wasn’t actually what they did. Instead, they created an experience for a patient. They were more like Disney than they were like a factory.
At that point, they kind of switched gears and started managing the practice based on how patients experienced it. That was a dramatic change for them in practice, which carried through into the hospital and later into the surgery centers. Even the best hospitals in Phoenix have patient satisfaction scores in the mid-seventies. Dr. Lieberman shared that if the scores for his surgery centers go below 99.5, he’s pissed. He believes they can create a totally different patient experience in a surgery center than they can in a hospital. They now have over 30 surgeons using their facilities, and they want to make sure the whole team is committed to making that perfect experience – not only for patients, but also for other stakeholders such as surgeons, families, and staff.
[7:57] Creating a patient experience that sets the practice apart
They start by identifying what they think is the best. Through looking at research and speaking with experts, they have best practices for each category. For example, if Dr. Lieberman or one of his family members needed a knee replacement, he would want to use a robotic assisted, minimally invasive, muscle-sparing, outpatient approach. So starting from that point, they can advise their patients that there are 50 surgeons in the area that do knee replacements, but maybe only 10 of them know how to use a robotic assisted technique. Of those, maybe 5 do a quadriceps muscle-sparing approach. They can then bang on the door of those 5 surgeons and get them to come to their surgery center to try it out, and then they pair up that surgeon with that team and equipment, and they use digital marketing to get patients who want those same kinds of experiences.
They really focus on marketing at Phoenix Spine and Joint. They have 2000 followers on Facebook, and just over that on YouTube. Their website gets over 15,000 visitors per month. They try to get the message out about why they are the best and how they offer services. They try to create a horizontally integrated patient experience, where they offer the best surgery from the best surgeon, and then give the best patient experience. It starts from when you park, and goes on through how you get into the facility, how they treat your family while you are in surgery, how it feels when you leave, pain management, perioperative pain control, and all the other factors that go into that experience. Dr. Lieberman likens it to picking the right movie to show you, putting you in the cushiest chair, serving you the best drink, and just making it an overall great experience for you to watch that movie.
When you are considering spine surgery, the outcomes are as good or better than any other form of orthopedic surgery, but if the complications can be horrendous. It’s not that the outcomes aren’t good, it’s that the risk is off the charts compared to other surgeries. If the knee replacement surgeon doesn’t use a robot and puts in the wrong size implant, you might be off, but your bone is going to remodel and you can do physical therapy. A year later you might be just fine. If a spine surgeon makes a mistake, you’re paralyzed. It’s different stakes and different risks. It’s also, though, a different reward. With neurological diseases in general, whether it is brain or spine, they are so much more functionally acute. Dr. Lieberman worries about people who don’t want to have surgery and want to live with the pain, because he wants to make sure they aren’t taking narcotics. The incidence of narcotic abuse is higher than the incidence of spine disease in our country.
[12:25] The process of opening a surgery center
Opening a surgery center, for Dr. Lieberman, was totally based on need. He was staring down a big pot of money from selling the hospital, so he could go anywhere he wanted and he didn’t need anybody’s permission. He decided to go where the competition was lowest, about a 20-30 minute drive from his home in central Phoenix. For most people, you would go into a surgery center with partners and your partners could make or break the experience. Doctors are star performers but they tend to be “crap managers and craptastic partners,” according to Dr. Lieberman. He observes that almost all the really unhappy doctors are unhappy because of their partners at home or at work.
Dr. Lieberman’s first surgery center was a tenant improvement. It was a medical office building that had a landlord and he had a broker who was able to get him a very generous tenant improvement budget. He selected an architect with a lot of experience doing surgery centers, which really is crucial. While the landlord had determined the construction company, he let Dr. Lieberman interview them. He had heard stories of surgeons who started out building their surgery centers and then years later still did not have an approved center. It was always related to an inexperienced builder, an inexperienced architect, or someone else in the process who lacked experience. Dr. Lieberman looked for people with experience. When he was working on his other centers, he kept the same team. If they worked well, he kept them. If they didn’t, he fired them and moved on.
By the time he started working on the second surgery center, Dr. Lieberman had more experience as well. He worked hard to make things better and easier for everyone involved. He points out that it is a pretty significant undertaking to acquire your own hospital or build your own surgery center, and it’s not for the faint of heart. You have to take control, and you have to be willing to roll up your sleeves, get in there, and get things done. If you are a busy surgeon, you may be a control freak but you also likely don’t have spare time. For most people, then, you are probably looking at finding a business partner or a manager who knows what they are doing and takes things seriously.
[16:49] Dr. Lieberman’s first job
Dr. Lieberman has only had one professional job: a neurosurgeon. He has been a self-employed neurosurgeon for the vast majority of his professional career, until he lost the ability to operate because of his tremor.
He did make bagels when he was in 7th grade, and he was a law firm messenger for his father’s law firm when he was in high school. During college, he was a math tutor in a computer lab. So he had some odd jobs, but his first professional job was as a neurosurgeon.
[17:46] What Dr. Lieberman would do if he was not in the medical field
For many surgeons, their skillsets are so focused that they are not applicable to much else in the job market. Dr. Lieberman shares that he would likely have to go from neurosurgery to flipping burgers, as his decades of training don’t qualify him to do anything other than what he already does.
[18:48] Dr. Lieberman’s YouTube channel
Dr. Lieberman has “reopened” his practice, but only on YouTube. He sees patients as a “fake doctor” live on YouTube, as they release episodes of their show (The Clinic) every Friday. The idea is to educate the public about spine and joint conditions by showing them what would happen in an exam room. It’s informational, and almost like a medical reality TV show.
[22:57] What Dr. Lieberman reads for news, information, or inspiration
He shares that he took a time out on the news a couple years ago, and he never went back. He does read a lot, both fiction and non-fiction. He enjoys classics, like books by F. Scott Fitzgerald and Hemingway. He also tries to read current books, and he also loves social media. If you set up your Twitter, Instagram, or Facebook to follow topics of interest, you can get great information from all over the world. Dr. Lieberman follows data science, artificial intelligence, and anything having to do with space. So his ‘news’ is basically a curated feed, and his entertainment is mostly classics.
[24:39] What Dr. Lieberman does for self-care
Every day, Dr. Lieberman tries to set aside time to make a list of things he needs to accomplish by the end of the day that will most impact his life. There are just some things that only he can do, and making these lists improves his discipline to get things done. Then at the end of the day he doesn’t feel overwhelmed, behind, or regretful.
[26:13] Whether people are born with an innate desire to heal others
Dr. Lieberman believes that people are born with a desire to heal. In Judaism, they call it Tikkun Olam – the desire to heal the world and to make it a better place. For doctors, he observes that you will often find a common history in that they had a parent who was ill and they wanted to help. They saw the role that doctors played in taking care of that person that they loved the most.
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