Episode 45 - Thoracic Outlet Syndrome (TOS), Administrative Costs And Being An Entrepreneur

Have you ever felt numbness in certain areas? Like when you are shampooing your hair and all of a sudden, your arm goes numb? If you have experienced this, then you might find this episode extra insightful. Dr. Beth Bagley and Dr. Frederick Schurger discuss the complexities of Thoracic Outlet Syndrome (TOS), examining the various impacts it can have on your arm, hands, and even back to the head and neck. This boring-sounding diagnosis may be one of the most underappreciated issues of not only neck issues, but also postural issues. They also touch on how being a small business owner without a lot of administrative input helps us save you money on your healthcare needs. Tune in now!

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Thoracic Outlet Syndrome (TOS), Administrative Costs And Being An Entrepreneur

Dr. Bagley, how are you doing?

I’m doing fabulous. How are you doing?

I am doing excellent. Folks, welcome to the show. We’re getting back to it.

We’re talking about feet. We talked about that. We don’t go into feet on this show. This is not the Feet Show. That’s a whole different channel.

Except everyone who knows me knows that I’d rather not wear shoes because then I have to show you how to do half of the exercises and therapies that I want you to do on your own. I’ve got to take my shoes off to do it anyway, so it’s easier.

If you do go see Dr. Schurger and he doesn’t have shoes on, yes, he’s weird, but he’s also doing it for a good reason.

There’s a practical purpose to it. In my personal opinion, it helps me with my adjustments. You also won’t see Dr. Bagley in a pair of heels.

Never, ever. Not one time.

She does not need them.

I don’t. Even if I did want to wear them, I wouldn’t either because it would destroy my adjustment in my back. I don’t think they’re good for us.

Let’s talk about stuff and things going on. We have a couple of things we want to cover. Where do you want to start?

Honestly, I love that topic of TOS. TOS is Thoracic Outlet Syndrome. I think we should start off by talking to the readers about what it is, like what Thoracic Outlet Syndrome is. Thoracic means the thorax. Outlet is something coming out and syndrome is something’s wrong. They’re talking about the area right here in the lower part of the neck where the scalings and the first rib live. There’s a lot of people who will start having what we call brachial plexus issues, which is areas coming down the arm. They can get numbness. They can get tingling. They can get weak. If they put their arm up, if they’re shampooing their hair, all of a sudden, their arm goes numb or dead.

They can’t even get their hands up to shampoo their hair.

That can lead to frozen shoulder and all sorts of things. This diagnosis of Thoracic Outlet Syndrome, it covers all of it. Honestly, I think it might be over-diagnosed. What do you think?

I would probably even think it’s underdiagnosed because there are multiple components to this going on. We have nerves coming out at the neck, going behind the collarbone. It’s called the clavicle, but most people call it the collarbone, how that drops down and behind before it gets into the arm itself. You certainly have the nerves involved with that. You have the arteries and the veins. In fact, I’m seeing in some of the research that I’m reading that they’re actually starting to break out the components of TOS into the nervous component, the arterial component and the venous component.

Depending upon what is going on and what you were experiencing, they’re all going to call it TOS at the end of the day because I don’t think the diagnosis codes have changed that much. Sometimes, you need to identify this is more of a neurological issue. Is it a circulation issue, either coming or going? The next question is where the problem is. You commented before we started that many carpal tunnel problems are not carpal tunnel problems. They’re actually TOS problems. You’ve seen that. Go ahead and talk about that.

I have actually had quite a few patients come in with what we call radiculopathy. They were diagnosed with carpal tunnel. They got bilateral cuts on their arms and they still have the same problem. Those people, I believe, were misdiagnosed or diagnosed with carpal tunnel, but they also had what we call double crush.

It could be an aspect of thoracic outlet syndrome, but it also could be the outlet of the neck syndrome. If we’re coming from the like C4, C5, and C6 areas and if there are misalignments, impingements happening in the neck and the symptoms might be in your hand or arm, but if we don’t look all the way up to where it starts from, we’re missing a whole big problem.

It could be any joint from the wrist all the way up to the neck or any combination of those. It might not be even one area that is more problematic than another. When we start saying, “Where’s the problem?” Sometimes, you have to look at the entire path to figure out where it is. Back in my engineering days, it was not uncommon for us to see a problem on one part of the line that was operating exactly as it was supposed to, but yet something upstream or even downstream, oddly enough, was causing trouble that was causing that one spot to have a little bit of a hiccup.

As it were, the signal or the oscillation frequency of how that part was supposed to work wasn’t working in sync with everything else before behind. It’s always interesting to take that thought and say, “Is there something else that is involved here that can solve the problem before we need surgery?” Surgery is expensive. It’s permanent and it may not solve the problem if it is not where the problem is.

I’m not saying carpal tunnel surgery doesn’t work. It absolutely does work for some people if that is the problem. My opinion is we always start with the least invasive procedure first. Maybe it’s icing. Maybe that’s the first thing you do, or stretching. It should start with that and maybe a low-inflammatory diet and going to chiropractic because we need to check to see what’s happening. If there’s a problem in the neck or shoulder problem, we pretty much can figure that out.

If none of those things work, and it might be months, it might be 4 or 5 months later that you realize, “None of these things work,” then we go to surgery. If I was having that issue, I would never start with surgery. That would be the end thing. I hope to never have to have something like that. Honestly, I don’t think I will because I know the things to do to stop things like carpal tunnel from getting worse or even occurring in the first place. If I know how to do it, then you know how to. All patients can benefit from this.

I’m going to go down a quick list of symptoms that are pretty common with thoracic outlet. We have some paresthesia, like numbness or tingling. All five fingers, fourth and fifth fingers, first and third fingers. You can have a combination or you can have either all 5 or the thumb and the first 2 or the last 2 because they’re broken up depending on how the nerves go out. That’s a longer dissection, literally, of the brachial plexus.

You’re typically going to have the last two fingers having problems. You can have pain across the shoulders, which would be the trapezius supraclavicular pain, which is, again, pain over that collarbone, chest pain, and shoulder and arm pain. Occipital headaches can actually go back because there’s a lot of stuff that comes from the shoulder blade back up into the skull as far as attachment points.

Upper extremity pain, upper arm pain, everything gets worse when you raise your arms overhead. This could add to your overhead work if you’re doing a lot of overhead work. Basically, pain around that shoulder and rotator cuff area. All of that might have some problems. These pieces might not come together easily, but you start seeing them and you’re like, “All of that is related.” There are a number of different things that can be causing problems.

In fact, one thing that’s probably missed because these scaling muscles, these are muscles that sit on the front of the neck, the phrenic nerve comes through this as well. That might cause some problems with your breathing. You might feel like you’re short of breath because that’s the area where these handful of muscles come together. That phrenic nerve drops right through that. It can be pinched.

When people have a phrenic nerve problem, which is C3, C4 or C5, they also can have an increase in anxiety. The reason is that if you can’t feel like you breathe, what does that already feel like? That feels like an anxiety attack. If you’re even at all prone to anxiety, then this cycle starts stirring. It might be a physical problem that’s happening to you, even though if you went to the medical doctor, what would they throw at you?

If you can’t feel like you breathe, what that already feels like is an anxiety attack.

There’s a pill for your anxiety.

“Here’s a pill. Here’s an anxiety pill. Here’s some Xanax.”

One of the things we should also point out, as we’ve talked about, is that those lower cervicals, especially C3, we joke about it being the mood bone. Anxiety might be the mood, but it also might be anger.

We renamed it.

Tell me, what did you rename C3?

C1 has that name, Atlas. C2 has a name, Axis. I also call him the dizzy bone because I do think it correlates to dizziness with some of my patients. C3 is called Moody Bob because it was a patient, Bob, who had his C3 out and we were talking about being the mood bone. He goes, “What’s the name of C3?” We’re like, “It’s Moody Bob.”

That’s how things get named.

Everybody now knows C3 is Moody Bob.

Those are some of the big ones that always stand out. Where is the problem? Everyone wants to say, “You’re only going to have a thoracic outlet right there at the neck.” One of the things that I think people miss, and you might not even notice that you have a low-level thoracic outlet problem until it’s been there for a very long time, is when you lose your posture and everything cramps down behind that clavicle. It’s having pressure on all of those structures on that brachial plexus, the artery and the vein coming back.

If we lose our posture, we’re going to have more problems with our arms in general. What’s always curious when they start looking at longevity factors, I haven’t seen a good longevity factor that looks at posture. I haven’t seen that. I’m not saying it’s not out there, but they always look at and say, “People who have better grip strength have better longevity.” Do you get your grip strength thing out and you train that or start saying, “That means I’m going to be strong all the way through.” The latter is probably more the truth of the factor. How much of that is going to be better when you have better posture?

I think that’s something that people should be thinking about. If they get diagnosed with thoracic outlet syndrome and they don’t know what the answers are, definitely start with chiropractic. Quite honestly, I felt like I was poorly taught this in school. I think it’s probably one of the most interesting and relevant diagnoses that chiropractors, in general, not just upper cervical folks, should be addressing because there’s so much that it tells us about what’s going on in the neck and the shoulders. How do we start turning that around for an individual so that they can start doing better?

What I would find interesting if I was reading right now is somebody’s reading saying, “I have bad posture.” Obviously, our first thing is going to be to get to a chiropractor and get adjusted because that’s going to be the number one thing that you can do for posture. If your head’s on straight, posture is so much easier. Staying in good posture is night and day difference. You can get in good posture.

However, there are still some things that you can do to help posture. One of the things that I have my patients do is called the Brugger Relief Position. That’s when you stand up with your feet shoulder-width apart. I always say put your thumbs up to your sides and back so you’re going to turn your hands backward so that you’re putting your shoulders back and pinching between your shoulder blades with your arms out.

You hold that while breathing. I try to get people to deep belly breathe at that point, if you can learn to do that. It is a skill. Hold that for about 30 seconds. What you’re doing is you’re stretching your pec muscles, which get tight when we’re sitting in front of a computer. You’re activating many of your back muscles at the same time. It’s a stretch and an exercise at the same time because we’re stretching and exercising, turning on things that are turned off, turning off things that have been tight and all pinched up all day.

That’s something that I have my patients do multiple times a day if they’re in or posture positions like desk work or if they’re hairdressers, dental hygienists, or dentists between patients. Honestly, we do that a lot between patients here in the office, too. That’s one of the ways that we can put a stretch and exercise in our daily life, and honestly, it helped me get through school because school posture was awful.

I have no doubt about that. It’s probably not the way you teach it, but the problem that people will have hearing is, “That means I need to pull my shoulders back without changing how my neck and my upper body are.” What you’re describing is not that. A lot of people hear that. There’s something different. You’re not pulling your shoulders back, but you’re lifting your chest up by doing that.

Doing posture positions, you’re not just pulling your shoulders back, you’re also lifting your chest up.

There are many exercises that can be done and you can hold your breath through the whole thing, but you’re not doing them right if you can’t breathe through them because you’ll have other muscles that need to relax that need to compensate. As you said, getting that upper chest open and stretched can oftentimes be a problem. I’ve been having people lay on a foam roller on their back. So perpendicular to their spine and lay on it. Foam rollers are not just for rolling. They are literally a place to lay on to give you a fulcrum point.

You’re saying it like lying it along the spine?

No. Perpendicular.

Across the shoulders?

I would actually bring it down a little bit. What I’m trying to do is bring the middle of the thoracic straighter. I’m trying to get extension. You naturally have a kyphotic curve going forward in the thoracic spine. Basically, it’s a forward-moving curve towards your organs. What I’m trying to do is reintroduce a stretch so that you can get into extension. You’re never going to reverse it so that it’s going in the opposite direction.

The cervical curve can reverse. That’s bad. What we’re trying to do with the thoracics is stretch it so that you can get into better extension, which will help open up your spine, open up the rib cage, and prevent that from rolling forward. It also will work against Thoracic Outlet Syndrome. I like the idea that you can find a foam roller pretty much anywhere. You can walk into Walmart, Meyer, or any place on the planet and you’re going to find a foam roller in the sporting goods area.

What we’re trying to do with the thoracic is stretch it so that you can get into better extension, which will help open up your spine and rib cage and prevent thoracic outlet syndrome.

I think that is too thick for the average person to start with. I’ve been buying three-inch PVC pipes, cutting them up and prepping them for patients. Even a one-inch pipe, for some people who have what they call a kyphotic or you’re rolled forward, maybe you have the dreaded dowager’s hump and you’re trying to figure out how to undo that laying on even a one-inch pipe or even laying flat on the ground.

It might be a lot for someone who has a hump.

You need to work on this slowly, and maybe you’re used to having two pillows under your neck. Go down to one pillow. Work yourself so that you can lay flat without that problem. The deep breathing is huge for that. That’s where I would start with most people. It’s a pain. I’m not going to say that it’s not, but if you got yourself in that situation, I’m offering ways to get out of it without drugs and surgery.

When we start talking about surgery related to Thoracic Outlet Syndrome, it is very poorly managed. This one study I’m looking at here basically says improvement fails to occur with severe ongoing burdens for patients. You might get temporary relief with the surgery, but it’s not going to be long-lasting.

I actually have a patient. He doesn’t come in very often anymore because he does so well. He had surgery to resect a rib for thoracic outlets. This was before he became a patient of mine. I can’t tell you one way or another if this would’ve helped him before, but when he did come in, he was having the Thoracic Outlet Syndrome symptoms again, even after the surgery. When we got his head on straight, it stopped.

That’s great.

It’s pretty amazing. He could have actually had some pretty severe Thoracic Outlet Syndrome and maybe it wouldn’t have stopped if he hadn’t had that. There can be something going on in more than one place. I love that we get to do something so minimally invasive yet so effective every day.

One of the best parts about what we do is we get to be our own bosses first. Quite honestly, we’re able to offer a service that, as one of my patients said, was so great to be able to help so many people, and yet we’re able to offer this service that helps people get better at a fraction of the cost of what a lot of healthcare is out there.

One of my patients was getting a dental implant for a tooth that they had to have removed. We need to charge more. I’m not going to. I want this to be affordable for more people. Once I see the prices, they’re paying for one thing, one tooth that there’s no nerves going to that tooth. You can see it. I get why people don’t want to pull in their smile, but one dental implant costs $5,000 to $6,000, and that’s a few years of upper cervical care, if not more.

The work we do, as with the Atlas, the upper cervical is a premium service. I’m not going to pretend it’s not. Compared to some of the chiropractors, places like the joint, people will pay more here than they will there. The question I have is, certainly, the dental surgeons have a higher liability insurance to be able to do that. They’re working for themselves. I heard one doctor say that opening up a dental office costs roughly $500,000 to $1 million.

Equipment and build out all the things. We do have our CBCT, they also have CBCTs, but they also have much more equipment.

Much more overhead. I saw this stat here. I was scrolling through Instagram here earlier and this picture came up when looking at administrative costs and administrators versus physician growth.

We’re thinking probably more hospital-based right now.

From 1970 to 2009, the projections of administrative growth have been just as bad. It has been astronomical for people who are not caring for patients or not seeing patients. When you consider the cost of a physician, you might have a few administrators who are making the same amount as a physician. When you have this many administrators doing all the extra stuff. Administrators are not nursing staff. It is not the people who are doing the healthcare work. You have people literally doing paperwork here in this case. It is no surprise that healthcare has gotten so crazy.

We were actually talking before we started. I don’t think physicians should be paid any less. The money they make is well worth it. Honestly, maybe they should be paid a little bit more, if anything.

$443,000 a year for an orthopedic surgeon. I think that’s fair.

It’s fair, if not low, in general, when they’re standing for surgery for 6, 8 hours at a time or more.

Cardiologists sometimes do 12 to 16 hours. Some of the surgeries they’re doing are crazy expensive and crazy intense.

The thing about it is that they are making a good living and deserve a good living for that. Healthcare costs are still outrageous. It’s not because the nurses and the doctors are making more money. It’s not them. It’s all of the extra stuff. It’s that a Tylenol costs $700, and that’s all mostly because of the insurance cabal that has sprung up. We’ve talked about insurance companies before. I was on a Facebook group. I do consider Medicare an insurance even though it is socialized medicine. Inflation has gone up 10%, 15% in the last few years. It’s quite a bit, yet reimbursement for chiropractors has gone down a few dollars for adjustment fees. It doesn’t make sense. I don’t take insurance. You take a little bit of insurance.

Healthcare costs are still outrageous.

No, we just do Medicare at this point.

We have to do Medicare. As chiropractors, we have to do Medicare.

It’s Federal law.

I’ll follow the law. Even if I think it’s not right, I will still follow it. Reimbursements for chiropractors, in general, have gone down, and I believe reimbursements for medical doctors have gone down somewhat, too. Things cost more, so where’s the money going? Administration costs and insurance companies are making billions of dollars because they are not non-profit. They are for-profit and they have shareholders. When there are billions of dollars of profit, we should all invest in insurance companies. I’m not going to because I don’t want to.

I hate to say it, but it makes good sense. It’s a good place to put your money. The bigger thing is we, as small business owners, love our job. If we didn’t, we would be back in the corporate world where we both came from. What does it take to be a small business owner? It takes a lot of work. I was listening to one of my podcasts and he was discussing how do you become more prolific at what you do. It’s like, “If I had the money, I’d be able to do this.”

Maybe, but if you also had the drive to get the degree to work with somebody to make the money to understand and have a business plan, even if you do that on a shoestring budget, you will get further than waiting for someone to show up and give you the handout that says, “Here it is. Here’s the magic loan that you wanted. Here’s a grant. No, you got to start doing it and doing the work. The sooner you do the work, the faster you’ll get to that point.”

I wholeheartedly think you’re correct. If you sit around and wait for the perfect time, place, or anything, you’re not going to find it. If you want to start a business, jump in and do it. You’re going to make mistakes and those mistakes are going to be expensive. That’s the risk, but the rewards are great. If you have a passion for what you do, which both of us do, you will be successful. There’s good days and bad days. The good, the bad and the ugly. The good is I’m on my own boss. The bad is if I want to take a vacation, I’m my own boss.

If you have a passion for what you do, you will be successful.

Currently, I do have an associate, Dr. Ladd, who is licensed in the state of Missouri. If I want to take a vacation right now, she could tend to my patients. I don’t want to take a vacation right now, but if I did want to, I could. Right now, you don’t have an associate, so nobody sees your patients if you took a vacation or a week off. Do you still have to pay rent?

I still have to pay rent.

All of the things. Not only does a small business owner who’s a solo practitioner have to take time off not seeing patients, so you’re not bringing any income in that week or two weeks or whatever you want to do, but you have to pay all the bills. If you have employees, you still have to pay them. You have to pay for your actual vacation. You get double hit.

Some people call that the golden handcuffs. Yes, you have this beautiful life that you’ve built. You’ve helped so many people, but you’re handcuffed to your practice or to your business. You could be a plumber, it’s the same exact thing. Hairstylists, same exact thing. That’s the service industry. You don’t make money unless you are doing what you do.

I think the good, though, is that when you’re passionate about what you do, you want to mentor other people to do it. That’s one thing I know you’ve done in the past and I’m currently doing, and I love that. I love teaching either chiropractic intern fledgling chiropractors or new doctors how to run a business, talk to a new patient, or be a doctor. You’ve learned a lot of that in school, but you don’t learn a lot of that in school. You learn how to pass your boards in school.

Unfortunately, that is definitely the case.

I think the good is that I get to choose who I work with. I get to choose who I employ and I get to make my team happen. If my team is not good, I get to change that myself. I always look back at myself as if I have something going wrong, it’s me. We were singing this song by Taylor Swift, “It’s me. I’m the problem. It’s me.” If you’re a good leader in your organization, when there is a problem, you first want to look back.

If that’s me in the mirror, I could have made a poor hire. It could be that I didn’t train this person effectively. It could be that I didn’t make myself clear. I’m taking responsibility for any of those things because the buck stops here. If you were starting a new practice now, knowing what you know now, what would you do differently that you didn’t do in the beginning?

If you’re a good leader in your organization, when there is a problem, the first thing you want to do is look back at yourself in the mirror.

I’d probably change up the layout of my office. I tried to keep my build simple when I moved into this location. What was nice about it was that it had the rooms laid out the way I wanted them to be. I needed a wall put up. I needed a couple of walls, I needed another wall opened up. I made sure that the changes weren’t over the top.

Looking back, if somebody’s reading that and saying, “I’m starting an office or I’m starting a business,” what would you tell them? You learn a lot of that stuff by doing.

One of the things that I would’ve done differently, for me, especially coming from the corporate world, you live in a corporate world as an engineer especially, you’re like, “The big pie in the sky goal is to get that corner office with the great view.” I’ve got a corner office with a great view.

You do have a great view. You got windows that are wonderful.

It’s pretty back there. I’ve had ducks outside the one window on and off for several years. Some days, they come back and they haven’t been there in a couple of years. The room for what I need for an adjusting area is too big. I utilize all the space because I have the space, I’m going to utilize it. I would recommend to any new doc starting off, find people who know how to do patient flow, which basically aspires to how long it takes a patient to get into your room and then get out. We’re in the middle of winter and everyone’s got their coats in their jackets and brings their coats in their jackets and stuff. It does take time.

One of the things that I would do differently, and I have it now, but I have two adjusting rooms. For the longest time, I only had the one adjusting room and the other room was a consult room. That’s all it was. It didn’t have anything else. I got rid of my consult room and combined my consult space with my imaging space, which is a little crowded with both X-ray systems in there. I’ve changed the spaces up. I’ve changed how I do my process.

I would definitely start with at least two adjusting rooms. I would have a third space, maybe even a fourth space, set up for other professionals. Maybe both those spaces could be occupied by a massage therapist or one massage therapist and another one being someone who does functional nutrition. Give them a space where they can do their work. They’re third-party independent contractors that pay rent.

I think if I were thinking about my office again, this would be my second location. I did get to do it once already. A few things I would choose about location is I would not be near restaurants ever again.

It smells so good, except for when they smoke.

I guess the restaurant next door had a grease fire or something. For a whole week, we had the smell of burnt food in the office. Don’t be near restaurants. I didn’t consider that. I did, but I was like, “I like this location,” and I made all the excuses. I would never do that again. Also, I’m a big fan of open adjusting areas. Go to some offices and look at the spaces and what they’re doing. Do you like the vibe of an open adjusting area? I love it.

I’ve got specific rooms. If I had a space that was conducive to open adjusting, I would still have a barrier between the two tables I’d have. I could go back and forth with the next person. My problem with the open adjusting is when you’ve got somebody who wants to talk and you need to get to the next patient, you are done with them in the room, they’re going to the resting room, or they’re going to the front desk to check out or they’ve already been checked out. You’re already going to the next patient to take care of that next patient. I love chatting with my patients. Some days, I have time and some days, I don’t.

You never want to make someone feel like you don’t care when you do. Sometimes, we have to move along.

Sometimes, you have to tell somebody. It’s like, “I have to get to here. I have to get there. I’d love to chat another time. We’ll pick up on this.”

If it’s something that is clinically valuable, but you don’t have time, just say, “I want to set the site. I do not want to rush this conversation. Let’s go up front and set up a time for a consultation. I won’t charge you extra for it so we can sit down and have that conversation,” and then finding a time that works. First of all, they’ll feel good about it.

I think another thing I would do if I were starting my business over is when I’m ramping up, like I’m a brand-new chiropractor and I’m ramping up with new patients, I would, as quickly as possible, as quickly as I could afford it, and if I had taken out a loan, I might do it right away, is hire an assistant. Not even a front desk assistant yet because I wouldn’t have enough patients for that yet. I would hire an assistant to help with marketing because it’s a hard position to hire for. When you find the right person, it is amazing. Once you are busy with patients, you don’t have time for marketing anymore. You have a minuscule amount.

Once you are busy with patients, you won’t have time for marketing.

I’m looking at my marketing schedule right now. Just to have the bandwidth in my brain to focus on that is very difficult.

Trying to switch it back and forth because the clinical and business brains are separate. The business brain works well with the marketing brain. That’s part of the business brain. When you’re in clinical brain, you don’t want to turn it off because you’re in the middle of seeing patients. You need that part of your brain turned on. I have to have separate times scheduled for my business brain. Sometimes, it works because I get pulled in seven directions in a day. If you’re starting off, schedule your marketing and business time and make that no patient time. Later on, when you have to fill that in with patient care hours, you can hire someone to continue that and your marketing won’t fall off.

For the patients who are reading this, they’re like, “Doc, this is boring. We don’t want to read this,” this is why we’re not available sometimes because we actually have to get work done that doesn’t involve patients.

That’s not fun. Patient care is fun for us. I would rather do it all day long.

Five or six days a week. I’ll come in on Sundays for you. People know this for a fact, but I have to do this other stuff sometimes.

People will look at our schedule and they’ll say, “You don’t work that much.” Erin says the perfect thing. Erin is our front desk, super CA, super chiropractic assistant. She’s amazing. She says, “That’s the time the doctor sees patients, but we are in the office a lot more than that.” It’s so true. We are having meetings. On Thursdays, I’m here from sun up to way past sundown. That is my choice. I love it. I don’t want to change it, but I am not seeing patients the whole time.

One of the other things is if you’re reading this and you’re a student chiropractor, and you are like, “I want to start my own business, but I’m not ready,” that’s where associates come into play. You can do all the things you love to do and let someone else take care of the business stuff because I’m good at it and enjoy it, but not as much as patient care.

I’ve got all the systems set up. I’ve got everything. I just need associates to come in and plug into the system. When they’re plugged into the system, you get to grow. You get to make money. You get to see people. You get to change lives and you don’t have to do all the gross stuff that we have to do, like payroll taxes.

My wife Jean handed me the quarterly payroll thing to sign. I’m like, “All right, here it is.”

Fortunately, I know what I’m good at and what I’m not good at. One of the things I’m not good at is bookkeeping. I do hire a bookkeeper to do that for me.

That makes good sense. We’ve got an accountant who takes a look at everything at the end of the quarter to make sure everything’s where it should be. We’ve paid the tax man when they’re due.

It’s all part of business. I do think that a good point is why you aren’t open 40 hours a week. We work 40 hours a week. We’re just not open 40 hours a week.

Don’t tell them we work 40 hours a week. It’s 60. It’s easy.

In the beginning, it was. I can honestly say I don’t work 60 hours a week anymore.

It’s a little bit less.

I definitely put in 40 hours a week.

There are plenty of weeks where it’s 60 or 80 and it’s like, “I got to keep on going and plug and plug.” No, there are only so many hours in the day and we’ve got to utilize those hours to be as effective business entrepreneurs as we can be. We’re making good money so that way we can continue being here.

We’ve got to keep the lights on.

Quite honestly, there is satisfaction in doing this work, but at the end of the day, satisfaction does not pay the bills. There’s nothing wrong with that. That’s the capitalist society. I’m okay with that. The point is if it wasn’t satisfying and we didn’t make some money at it, we couldn’t do it. That’s not practical. Your husband, Jason, would love to paint miniature figurines all day long. That is satisfying for him. I know that for a fact.

He’d like to play the games.

He likes to play the games. I don’t think he’s got the time to do that, either.

He does sometimes. He’d love to do that, but that doesn’t pay the bills.

No, it doesn’t, unfortunately.

The last thing I wanted to say about the difference, that chart you put up, was the administration costs. Even years ago, when we started practicing, there were still some medical doctors who existed outside of medical conglomerates. There were some that saw patients out of a little office like we have. I don’t think I see those much anymore, except for what we call boutique practices.

I think they’re coming back.

Why boutique practices work, which is what you do is a lot of them, you pay a yearly fee. They have a cap of how many patients they have on their yearly fee. They might only see 200 or 300 patients in their practice, and everybody pays $2,000 or whatever it ends up being. Guess what happens? They have cut out the administrative fees because they’re not working with insurance companies.

I think we can consider our chiropractic offices to be boutique practices as we have also cut out insurance in general. I give people super bills, allowing them to turn stuff into their insurance company and get reimbursement, but I don’t have a full-time insurance biller in the back. I don’t have the administrative costs.

People are like, “Why don’t you take insurance?” I’m like, “It’s because it’s a racket,” but I don’t usually don’t say it like that. They don’t allow us to treat our patients like they deserve to be treated. They might say, “You get six visits and if they’re not better by then, you don’t get any more.” I’m like, “I’m not going to play that game. You’re going to get what you need and I’m going to tell you exactly what you need and I’m going to tell you what’s working and what’s not working.”

I’ll use a great example. I’ve got two couples coming in, and both are seeing great results. The one, they were both holding, and she needed to be adjusted more than her husband. Her husband’s doing pretty good. He started about a week later than her. He would have a couple more visits at twice a week. He’s doing so good. I don’t need to see him twice a week. They’re driving far enough. They can come in once a week. It helps them out. Quite honestly, it works out for where they’re at. This other couple, the husband started about a week or two later. He’s also doing good. He had one more twice a week scheduled.

He’s doing great. He’s going to come in. We don’t need to do twice a week for him and yet she might need a few extra visits. It works out. Why? As she put it, she’s got that little bit of a tomboy in her, I would say. She played with the boys and was warned that she shouldn’t roughhouse with them the way that they were roughhousing. She decided to do it anyway.

As a result, she’s like, “Why am I not holding?” It’s like, “Here’s why. By your nature, you’re not as strong as the boys. Sure enough, you might need a little bit more care.” We compared it to one of their friends who referred them in and how bad she was for 3 or 4 months before she started turning a corner. Your care needs to be met where you are, not where some bureaucrat has never seen you.

I don’t care if they’ve got an MD behind their name or an RN and that they said, “This is what the plan says.” They are not treating you. They’re not taking care of you. They have never sat down with you to understand your condition to do what you’re supposed to do. This is why we see administrative costs skyrocketing. You have administrators who, on behalf of the doctors, are trying to get some of this insurance through. There is that aspect.

This is why we see administrative costs skyrocketing because you have administrators who are trying to, on behalf of the doctors, get some of this insurance through.

The insurance companies are trying not to pay you or pay the doctors. It’s a fight.

This is why we don’t play in that game because Illinois had decent insurance until about 2010 or 2011. We billed insurance until then. Quite honestly, all of a sudden, it all dried up. I looked at how much it cost a patient to come to see me for the initial round of care versus how much their out-of-pocket was to see me. Someone who had insurance versus someone who didn’t have insurance. The cost difference was $100. What benefit were we getting for doing all that insurance billing? I don’t know because it was a lot of stress. People who bill insurance burn out of that job very fast.

It’s awful. Sometimes, you’re fighting for pennies. It’s ridiculous. It’s not worth it. Our healthcare system is broken. We’ve talked about it before. We’re not going to solve it in this episode. I can tell you that when a doctor, chiropractor, medical doctor or dentist tells you that it’s going to cost so much, realize there are other things built into that. Most of us aren’t trying to gouge you. There might be some. I can tell you, I’m not trying to gouge you. We try to keep it fair and reasonable so that anyone can afford this.

Sometimes, you have to make some sacrifices. Maybe you’re not going out to eat as much or there are some things that you might have to change to get through it, but it’s worth it. Honestly, after you’ve finished the initial phase of care, it’s so much easier. You might only be coming in once a month just to get checked. The hardest part is the beginning. Is there anything else you wanted to add to this episode?

I think that is the extent of it. I’ve talked about some of the wins that we’ve had. The patient, who is going to borrow some of her husband’s extra visits, needed to get adjusted extras. She was the one that had the Clydesdale clamping down on her shoulder. Not even there. Not even a pony. She’s making progress. It’s taking time.

It does. Some people take longer than others. That’s okay. Don’t give up hope. It is going to help. If the doctor has found a misalignment and we’re at least somewhat decent at fixing it, this is incredible work that we can do. Where can they find you, doctor?

I’m at KeystoneChiroSPI.com. Keystone Chiropractic in Springfield, Illinois. Find me on all the Google and all the socials. I’m out there somewhere.

Find me on all things. My web address is PrecisionChiropracticSTL.com. I am in the Western part of St. Louis County. You can find me on TikTok. I’m going to give my TikTok. @Dr.BethBagley on TikTok because I’m going to try to post more on TikTok. I’m going to do it.

We’ll see what happens, but we’re not going to get the heat button from them. I’m almost confident. They’re like, “Chiropractic? That’s not acupuncture.”

You have a good night, sir.

You, too. Folks, we’ll see you. We’ll be back.

I’ll be here.