Personal Finances Made Transparent​

Zwade Marshall, MD, MBA

You said it perfectly, Zwade.

Cheng-Huai Ruan, M.D.

Thank you so much for being on. And we’ve been talking in the background for a little while, but I’m having him on because there’s some just nuggets, such great nuggets that I wanted to share with you guys that I actually learned and so we’ll be tapping on that. But Dr. Marshall is Emory and Harvard trained double board certified anesthesiologist and interventional pain doc. He also does something really cool, he’s the co-founder of this platform called Doc2Doc Lending and it’s very unique and it’s nothing I’ve ever heard before. A chief medical officer of regenerative spine and a pain specialist. And he actually is the MD MBA, which is really cool. 

We’ll be talking about that a little bit ’cause that’s part of my interest as well, but he’s done research and he completed his residency in anesthesia at Brigham and Women’s, which is Harvard in Boston, Massachusetts. And we’re gonna talk about several things. So part of it, I’m gonna have you have the Doc2Doc Lending hat on, and part of it is gonna be actually your practice as well. And so we’re just gonna kind of get right into it, but I wanna start actually with your practice for a second. And so first of all, when you got into to private practice, tell me, you kind of told me a little bit about pain points that you had, but tell me a little more about like when you first started, what was your experience going to private practice? Was this something that you really expected?

Zwade Marshall, MD, MBA

Sure, well, Dr. Ruan, thank you very much for having me. Did I say your name correctly, it is Dr. Ruan.

Cheng-Huai Ruan, M.D.

Yeah, it is, absolutely.

Zwade Marshall, MD, MBA

And it’s a pleasure for me to be here and speak to your audience. So yes, I opened my own practice about nine months ago now, but my first gig out of training was in private practice. And so I know many of the residents and fellows that’ll be listening to this talk are probably wrestling between academia and private practice. And the challenge, I think for us, is that the way we’re trained in medicine is that we have learned how to tap dance or check the boxes for an academic career, right? 

We know how to present well so the attending that you’re working with is gonna appreciate the points that you emphasize what you know they care about. We know how to pretend to be researchers and publish and speak at conferences, even though it may not be your passion. We learn how to even teach residents and junior students, medical students, all as a part of kind of building up that academic credo to get a good academic job. But then in the last year, you may think, wait a second, do I love this kind of teaching lifestyle, the academic environment, the tenure track, the associate professorship, is that really who I see myself being in the future? Or do I wanna be a community physician where I kind of call my own shots? I mean, work with a private group where we get to kind of carve and create your patient base, do the marketing that’s required to build a business and also take on some of that responsibility that goes beyond clinical care. 

Most of those job functions and skillsets are not taught in medical school in residency. And I think it’s conferences like this one that kind of helps many of us realize the gaps in our training to build a practice and working private practice. For me, it was a little bit surprising in the sense of, a fair question, the sense of, there’s so much more than clinical medicine. Doing a good job is the fundamentals. Like being a good doctor that can actually clinically do the task is the baseline, is the basics. What makes you successful in private practice is everything else. It’s knowing how to be conversant with both patients, their family members, but also your referring physicians. 

Knowing how to lead a team in the sense that is this multimodal comprehensive practice model where there’s a physician, you’re gonna have nursing staff, you’re gonna have medical assistants, you’re gonna have a receptionist, and framing your workplace personality to inspire the confidence of your staff in addition to your patients, and thinking through what your strategic vision and practice philosophy will be and ensure that you get buy-in from the folks that work with you, things that you were not taught in residency or being a chief resident, but things that you have to develop over time. And it’s a learn on the job for many of us and some of us who’ve done business degrees or spend time in careers before medicine may have some of that muscle flexed already.

Cheng-Huai Ruan, M.D.

Yeah, absolutely. So you said it pretty perfectly, it’s about the team leading aspect of it, right? But I think that, so my wife and I are both physicians and we both had massive amounts of debt coming out of residency.

Zwade Marshall, MD, MBA

Welcome to the club.

Cheng-Huai Ruan, M.D.

Yeah. And so I think that part of the inhibitions for us to lead as we sort of get this imposter syndrome is like, firstly, you have this sort of like financial stress and burden. It’s like, oh my God, I gotta do this, right? And I better succeed. And that pressure’s on because we gotta pay back so much debt and that’s right there. And then you have, okay, well I went to medical school and I finished residency or finished fellowship and I am supposed to be fully trained, but I am just very overwhelmed. And what private practice really is, you’re right, there’s communication, there’s delegation, there’s leadership. A lot of that is not necessarily learned because most of us went to academic institutions where all the hierarchy design was within the academic setting. And very few of us actually had a full sort of like private practice setting with the dynamic that is just very different. And so I also sort of had that shock. And so, how do you, tell me what you kind of went through with yourself and how did it transition you into developing this platform, this Doc2Doc Lending platform.

Zwade Marshall, MD, MBA

Sure, so I think I like the way you frame that in that there’s the delegation, the leadership aspects of private practice, but also the other part of it that a few of us acknowledge is that there is a sense of, if you don’t do academia, you’re somehow selling out from the academics, right? There’s this, the hierarchy is one that’s trying to promote more academic doctors. So if you ask your attendings questions about the money, the reimbursement, salaries, bonus structures, incentive plans, you’re almost embarrassed to ask the question because the thought is that you should be a physician that takes care of patients and you divorce money for medicine and you’re a good doctor that way. 

And so we leave training hamstrung by the ignorance because we couldn’t ask the question and feel comfortable asking it. In my case, I thought that I came out of medical school like you with north of $200,000 worth of student loan debt. And the average for the US now is 225, for the physicians that graduate medical school. And your FICO score is often going to be suboptimal, subprime, less than 700, because you’ll likely have a lot of credit card debt. And your debt to income ratios are gonna be askew. You juxtapose that with the fact that you’re earning 54,000 bucks a year in residency in average. And if you have a family, you have a wife kids during that time, it’s gonna be a financial struggle. 

And so finding that bridge from a time of financial duress to building a career in medicine often requires that we do some transition period where it may be the first job being in academics, having a chance to kind of get your sea legs under you and figure out your financial situation and getting a little bit more comfortable and cash secure compared to being cash insecure from all the debt and low income that you’ve had, or becoming an associate in a private practice where you’re gonna pay your dues, work your way up, hope to become partner and participate in your value creation as a doctor, right? And oftentimes you’ll be paid on a salary and your productivity is gonna be worth multiples of your salary. And until you become comfortable enough making that leap. 

In my case, I realized about two and a half years after I started my private practice gig that the economy of Zwade, the things that I did as a physician within my private practice was worth about 7.5 times what I was being paid in terms of compensation. And I say that to say, I’m in a very unique field. I do spine interventions. I own an ASC. So my clinical care, the procedures that I do, that’s compensated in terms of facility fees. The cognitive aspects of what I do, the seeing clinic patients, that’s compensated for in pro fees. Then I order urine drug screens for patients to manage their medication regimen. That’s also compensated. There’s anesthesia services associated with my procedures. That’s also a part of the revenue streams for the practice. 

There’s durable medical equipment, also revenue stream. And so I can go on and on and on. And when I think about the risk versus the reward, if I left my private practice associate gig or even becoming a partner in that practice and were not on my own and controlled all aspects of the economy around me, and then if you also have had success at marketing and growing the business where you know that the marketplace is responding to you, it could be because of your board certification, it could be because of your training, it could be because of where you’re located, having a paucity of specialists in your field. If that marketplace is responding to you at your current institution, whether it’s academia or in a private practice as an associate, then you get the extra kind of fuel that’ll motivate you to leave and take the risk of jumping. 

The beauty of it in my case that I made the jump during COVID because there was a displaced market. So a lot of smaller groups closed. There was forced quarantines and forced shutdowns, stay at home was in many states. And so there was no one leasing space in medical buildings and so real estate was cheap. There was no one buying OR tables, CR machines from Henry Schein and McKesson because business was slow. And you had a bunch of displaced patients who couldn’t go to their regular doctor. And so if you had a motivated ambitious doc who was willing to lever with assets to get capital, to purchase equipment at a discount, get leases where landlords are paying premium dollars in tenant improvements for long-term leases, it made a perfect storm for me to make the leap.

Cheng-Huai Ruan, M.D.

So you were able to assess your risk though, right? I mean, this is not something you learned at like Brigham and Women’s, right? This is something that you kinda took aside and be like, hey, there’s other things that are here and I must be able to assess those risks and move those chess pieces around me. And it’s exactly what we talked about. But I’m gonna go back to the first thing that you said that really rang true with me is that, whenever you’re train in an academic institution, it’s almost like frowned upon by you like going away from the academia. And as you were talking, you were sounding like my father there, he’s like, you’ve gotta us, does MD-PhD. 

So you got to stick with your academia and stuff like that. And so I think what you said is when you start in training and then you’re exposed to a very biased group of individuals, I would have to say, right, and then you get into private practice, there’s no guidance there and then there’s no financial education there. So that’s where most people get lost, but now a lot of people were thinking this, and they’re looking at your name tag, and say like, oh, this guy understands, he’s got an MBA, right? And so from the business side, how do you think we should really approach funding, right? And then also, on the personal side, how do you balance the aspect? Because I didn’t really understand what lines of credits were, I didn’t know what that was. I didn’t understand debt to income ratio. If you asked me what FICO was, I thought it was a dog’s name, right? I had no clue. And so, like, how do you even get into this stuff? Like how did you get into it?

Zwade Marshall, MD, MBA

Sure. So I was in medical school right before the Affordable Care Act was launched. And I realized in the conversations around having healthcare become more about this comprehensive ecosystem. If you weren’t at the table, you were probably in the menu. And doctors that put their head in the sand and didn’t kind of appreciate the business aspects of medicine were gonna be left behind. So the decision for me was pretty easy because I was in medical school between third and fourth year. And I chose the MBA where I was given a tuition scholarship to do it and it was all part of this kind of academic exercise of being in school. And it didn’t feel like I was giving up much. 

So it prolonged my time to earning by a year, and there was an opportunity cost to that, but it didn’t feel gripping for me then. And so when doctors ask me now, the ones that are in practice or already established, should I go back and do an MBA? It’s not an easy yes. Despite that I’m gonna tell you in a few moments that it was the best and most transformational educational experience I’ve ever had, including residency and college and medical school, in the sense that it reframed the lens through which I saw the entire world and most specifically, medicine, and a lot of things began to click. And I realized then that I was more conversant and end up in the kind of a vernacular around business and business relating to medicine that was unique for many of the decision-makers in hospitals, where all of a sudden, I saw them view me differently from my peers. 

And so I was being included in conversations that my peer group were not included in. And then you begin to see opportunities where others wouldn’t have access. It’s kind of insider trading almost, where like, okay, this market, if I moved to Peachtree City in Georgia, I realized that our VC partners at my old employment place saw that the Paramix was 87% commercially insured. Government payers comprised less than 15%. That’s a big positive for that marketplace. The second thing is there were only three pain doctors within a 25 square mile radius. I learned all these things by being at the table. Now, if you’re in practice already, and you’re thinking, should I go back? The reason why it’s a complicated answer and maybe it’s not yes, it’s because a lot of the skills that I learned in business school are not hard skills. 

I didn’t go to business school and learn how to do the accounting for my practice. I still hire accountants. I don’t do the market analysis myself, I still hire those consultants for that as well. I just know how to connect the dots and see the big picture. And it’s a lot of networking, it’s a lot of like strategy classes where you kind of see the case studies around how good companies are built and most instructive, why the bad ones fail. And you begin to see that I would have made that mistake had I not been in his class to know that that that’s a critical mistake for an early stage company if you overspend on X and not on Y. So it was a transformational kind of reframing year for me. Now to the root of the question in how do you get to the financing part? Like what happens? How do you understand FICO and all that stuff, because we’re not trained in that bit.

Cheng-Huai Ruan, M.D.

Correct.

Zwade Marshall, MD, MBA

I co-founded this company, Doc2Doc Lending and it was really founded on that principle. I was a student moving from Atlanta to Boston for residency. I had, like I said before, north of 200K in student loan debt, I was making 54,000 bucks a year. My FICO score was sub-700. The banks looked at me as a high risk of borrower because on the traditional metrics, I should have a relatively high default rate. And by relatively high, I mean like a 23% chance of defaulting on personal loans because personal loans have no collateral. But you know and I know and all your listeners know that a anesthesia resident just marched into Harvard is on a trajectory to earn a significant income, you know exactly when it’s gonna occur, the residency is gonna be four years, fellowship plus one, and so you know when they’re gonna be needing to repay student loans, when they’re gonna be getting access to buy their home and buy their car and disability insurance and term life and all the verticals there. So Doc2Doc looks at our borrowers prospectively. 

We underwrite, not just based on where you are, but where you’re going to be. And it puts cash in the hands of physicians who couldn’t otherwise access it. Now, what do you do with that money if you’re thinking of going out on your own in a private practice to the context of this conversation? The first thing that our doctors often do is get rid of credit card debt, that revolving debt has a drag on FICO scores. And that balance is the amount of cash that you have in balances on those credit cards relative to the credit card limit that really hurts. If you use capital-like hours to get out of a revolving debt situation like a credit card into an installment loan, which is what our loan is where you make monthly payments to principle and interest, every payment actually helps improve your credit score because an on-time payment, and zeroing out those credit card balances helps to boost the credit score, that’s number one. 

The second thing is you’ll need to have personal cash as equity or collateral to finance the larger loan that you’ll likely need to start a practice. So I mentioned the cost of leases and tenant improvement allowances and having to buy equipment. Well, how do you get there? Now, the banks know, they’re very well aware of how well doctors do when they’re already established physicians. And so they’re willing to underwrite loans for a half a million dollars or a million bucks for a GI practice with a surgery center. But to get that money, you gotta have good credit, the personal credit, because you’re gonna be the personal guarantor for that business loan, and you’ll need to have an equity infusion of your own cash. So if you don’t have the liquidity in savings, you need to be able to lever either your 401k or personal cash or a loan-like ours to put with your cash that say, I personally believe in this business enough to borrow money on my good faith and strength to get access to a larger loan to fund the business itself.

Cheng-Huai Ruan, M.D.

So you’re basically building your foundation, right? Well, first with the Doc2Doc personal loan, and then you just kind of build upon that. And I think that is a concept business that in my head, it’s kind of backwards for most of my life is because I was taught never to really go in debt or get any loans because, well, I’m an immigrant Chinese guy from immigrant parents. It was all like–

Zwade Marshall, MD, MBA

Debt is bad.

Cheng-Huai Ruan, M.D.

Like there’s that, right? There’s like, no, you don’t go into debt, but I’ve since then learned and utilized that there’s actually good debt and bad debt, and actually it really helps scale my practice, thank God. And so, but that’s also not really taught in med school. And I remember this, there was, so I went to a New York Presbyterian Queens in New York for residency. And I was asking one of my cardiac ICU attendings. And we’re just talking about like, hey, he’s like, hey, my wife and I, together, we’re approaching about $700,000 in debt, like both of us and like coming up. And I was just trying to get some financial advice. They’re like, no, you’ll just never pay your loan off. Just kind of leave it there, just pay the minimum, just do the best you can. And that was really kind of a depressing answer.

Zwade Marshall, MD, MBA

Because you already debt averse based upon your cultural experience. And so you think, I have this albatross around my neck forever.

Cheng-Huai Ruan, M.D.

Yeah, yeah, exactly. And so there’s cultural norms to sort of balance against, right? And so that’s why I was thinking in my mind is that’s always been like a backwards thing. I was like, well, I was like, it doesn’t make any sense to get a loan to fortify your credit to get a bigger loan. But most people don’t understand, that’s how business works. Especially if you’re trying to scale and we have other people in the summit specifically focusing on this point. And so, but let’s kind of go back to the mindset, for example. So you’re in your MBA program, and you said you use the lens of which you looked at life was different earlier. Are you able to give us that same lens? What does that look like for you?

Zwade Marshall, MD, MBA

Sure. So it’s when I decided to go into practice on my own and I began to think through the things that I needed to be successful. There’s always that imposter syndrome to your earlier comment where you think, I might good enough on my own because there’s no support. We’re used to having people around us, attendings, peers, colleagues you gonna say, hey, take a look at this MRI. I’m I doing the right thing? You don’t have that when you’re on your own, you don’t have it in real time. So you kinda have to get through that. But then building the foundation of the company, that lens comes into, how do I recruit and hire staff? The first employee, the second, third, and fourth will be instrumental to what my patients see or what my practice represents and how do I inculcate in them the kind of business ethos that I wanna exemplify and wanna be branded as. And so having the wherewithal and the kind of forethought to say, I’m gonna have an executive training for my earliest employees for a startup. 

The cost for that 1500 bucks for three hours worth of work and it’s priceless because they get buy-in to the business. They become what’s called first principle thinkers, where a lot of medicine is gonna be processed. When you answer the phone, here are the things you have to say. If someone asks this question, you say that response. Well, what happens if they go off script. A first principle thinker understands the practice value. What is the mission of what I’m trying to accomplish? And I’m comfortable with these core employees going off script because they will put the practice principle first and I don’t have to be prescriptive in every variable or every circumstance that they’ll have to encounter. And so that’s a part of the lens. The other part of the lens is knowing how to play to my strengths, knowing the things that differentiate me in the marketplace from the other doctors doing what I do and playing them up as much as I can. And so knowing that the market that 

I’m in, they care about branded medicine. And so within the first two lines of any marketing material, you’ll see Emory and Harvard trained, double board certified because many doctors were where I am, they’re not board certified for whatever reason. And so there’s a certain clientele, and I think this is across medicine holistically, where patients are no longer just coming from referral sources. They Google themselves, they search themselves. They’re a lot of self-insured plans where they’ll make the appointment themself. And so you have to speak to the patient, not just to the referring doctor. And so that’s a part of the lens. And so as I started and I began to see early success, I was often reminded of the things that I learned in formal business training that allowed me to kind of see opportunities where others didn’t see it and respond and react to things that I think are usually very challenging for a physician. No, it’s still a challenge for me, but it’s a little bit easier to navigate.

Cheng-Huai Ruan, M.D.

The first thing you talked about, seeing through the lens is something the I learned the hard way, is the first, you said the first two or three or four MAs or people within your organization, you’re basically, it’s like, hey, this is this core value of our company, and I wanna develop you guys into the lead leaders as well, so we can kind of grow together. Also very counter-intuitive from my immigrant brain as well, especially like when you start practice, when we start a business, as opposed to my parents, they’re just kind of doing everything and very micromanaging, but you can’t really do that if you really want to scale. And I really appreciate what you said. 

So I learned that the absolute hard way, if my staff is watching this, they’re crying and laughing hysterically right now, ’cause they’ve been with me the last four years and I’ve really changed as a leader. And then the second thing is, and this is probably the most powerful thing that I hope our audience gets is that you said that we really have to understand our target market or our clientele, right? Using words like double board certified and stuff like that. And reminds me of this book that Tilman Fertitta wrote called “Shut Up and Listen!” And I thought the book was written about, shut up and listen to him, like Tilman, like no, just shut up and listen to your clientele, right? And so this example that I always use is the eggs at 2:00 PM example, is that if you’re a restaurant and you stopped serving breakfast at 1:00 PM and then a customer comes in and they want eggs at 2:00 PM and you can tell them, no, we can’t do that, that doesn’t necessarily make any sense because you gotta shut up and listen to your clientele, what they want, you can charge on top of that if you want to, but you’ve gotta make them happy. And I do feel like that part is missing at medicine. 

So a lot of times, when people are, when I’m trying to troubleshoot something in our practice and I tell my staff, hey, eggs at 2:00 PM, this lady, he is like, okay, I understand. At least try to accommodate for the patient, right? And so, and I think that’s not taught and it’s especially not taught in academic medicine. I didn’t hear anything like that during grand rounds or rounds in general within my internal medicine and my chief residency over there. But what we hear is yes, you gotta be a good doctor, be compassionate to the patient, but it’s more than that. It’s the way you project yourself. It’s not what you are doing for the patient at that time is what is the perceived value of you and how do you get your core staff to also let other people know what is your perceived value. And it took me a couple of years to understand that, but, I guess that’s where, I think your opportunity costs for that one-year delay MBA was very valuable because it took me a lot more years to learn that aspect. So I really want to appreciate what you said, that really hit me hard on that one. And so, but now you got me interested in the whole Doc2Doc Lending thing. So tell me about sort of the growth story of that company. When did it actually start and where is it right now?

Zwade Marshall, MD, MBA

Sure, so my co-founder and I, Dr. Kenton Allen, we met at Harvard together, he’s anesthesia as well, currently works in New Hampshire and he’s actually the current president of the New Hampshire medical society. I told you my story about leaving Atlanta to go to Boston and you needed to get money and couldn’t at an affordable rate. His story is a little bit different from mine, but one that many doctors can relate to. He had two kids during residency and had his third in his final year.

Cheng-Huai Ruan, M.D.

Bless his heart.

Zwade Marshall, MD, MBA

Right, exactly. You realize quickly that that dog doesn’t hunt when you’ve got a income of X and expenses of Y. And so he needed to borrow money to kind of help to bridge his time in training, and also encountered the same problem that I did. In 2017, we decided, we had the idea and began to seek that associates and reach out to our peer networks around the need to access capital for most physicians and dentists. And we were validated in our hypothesis that folks needed them to get money and couldn’t. We then hosted a series of kind of like Shark Tank pitch sessions at the American society of Anesthesiologists Conference in 2018 in Boston, where we invited groups of the smartest people that we knew in our peer groups to kind of hear us pitch the idea of raising capital from doctors to give loans to doctors because we best understand each other’s needs. 

But it’s not just making a lending company, it’s an ecosystem. It’s having this conversation you and I are having right now with every borrower that calls and borrows money from us. We have direct doctor to doctor calls, where if someone says, hey, I wanna borrow $50,000 because I’m gonna buy medical equipment with it. And we say, don’t do that. That’s a poor use of funds. This is a personal loan. There are equipment financing loans that have half the interest rate expense that you should utilize instead. So we’re not looking to close every sale. We’re looking to help our peer group understand finances better, understand why some companies will advertise an interest rate and hide what the true APR is, which is a total cost of funds, inclusive of all fees associated with that loan. And so we’re meant to be the anti-bank, right? We wanna make sure that doctors think of us, like USAA is to veterans, Doc2Doc is to doctors. And we did quite a bit of listening the eggs 2:00 PM story that you just shared for us. 

A doctor said, we were offering loans of up to 50,000 bucks. He said, hey, we need more money than this. And we can’t get it anywhere else. I’ve got a startup practice and the banks are asking me for two years worth of tax returns and cashflow statements, I don’t have it. But I’m a gastroenterologist and the average income here is 485,000 bucks. I’ve got liquid cash that I’m gonna be earning, but I don’t have that track record. And so we were able to begin to increase our loan limits to fund entrepreneurial physicians like that one. And so we’re building not just a lending platform. 

We’ve grown from the time we issued our first loan, and now we’re doing significantly more volume per month and are proud of celebrating the milestones of loans out the door that we are. The thing that we’re proud of ourselves today is that during the course of COVID, while our peer lenders saw default rate in the mid to high teens, and that’s loan impairment, defaults, delinquencies, and modifications, Doc2Doc had zero defaults and we still have no defaults. We still have no 30, 60, or 90-day delinquencies. And that’s not because physicians don’t have hardship, but we were a community that takes care of each other. And so a physician borrowing from a physician, we know that there’s this implicit reputation consciousness that we all share and we’re gonna do our best to repay our peers, but also to ensure that as a peer group giving out loans, that we help our borrower base understand when to borrow, when not to borrow and what loan rates make the most sense for their use case.

Cheng-Huai Ruan, M.D.

So I mean, you guys also act like a consultant or a guide through this whole process, right? So that’s the powerful part because I, well, first of all, I don’t know anyone who would do this. And second, the banks were crazy if they wanna do this, because they would just lose out on a lot. So you are the anti-bank. So that’s very interesting. As you were saying, hidden fees and APRs and stuff like that, I’m currently suffering through that right now, so I can totally understand what you’re trying to say. So I mean, I think your company’s official name is Doc2Doc Lending, right?

Zwade Marshall, MD, MBA

That’s right, yes.

Cheng-Huai Ruan, M.D.

Yeah, so I think there’s a whole lot more to your company than just Doc2Doc Lending, it’s Doc2Doc strategies and lending too. And that’s what really, that’s why I wanted you on the summit, because I haven’t really seen that, but it’s something that I wish I took advantage of years ago. My wife would have probably loved me a whole lot more if I took advantage of that years ago, but we’re kind of learning as we go, right? Roll with the punches, that’s what we docs do. And that’s what this summit is for. And so I feel like you’re, so you got your MBA lens, your business lens, you came out, you went into private practice, now you’re a few months into all your own. And so what have you learned now, now that you’re nine or 10 months into your own practice, that you wish you knew when you first started nine months ago?

Zwade Marshall, MD, MBA

Yeah, that’s a great question.

Cheng-Huai Ruan, M.D.

And you can only pick one thing, I think.

Zwade Marshall, MD, MBA

One thing.

Cheng-Huai Ruan, M.D.

Yeah.

Zwade Marshall, MD, MBA

So I’m gonna contradict myself a little bit here.

Cheng-Huai Ruan, M.D.

Okay, I like that.

Zwade Marshall, MD, MBA

I told you about the investment, the upfront investment in people and what it takes to inspire your earliest employees to get the vision to become a first principle employee. What I didn’t appreciate going into this is how crushing it feels when you do all that and the employee still fails you, in that everyone is not meant to be treated as a first principle employee. Everyone should not be treated as a partner. There’s some folks that are truly just hourly employees that just wanna have that role. And the HR management, the drag, the emotional toll it takes when it’s your practice, it’s your financial investment, it’s your emotional investment. And when you invest in people and you give, and for the early days, when payroll comes around on Friday, it’s money out of your pocket, you write that check. And when you have someone that’s clock-watching or ignoring the phones as they ring or takes the phone off the hook that is set, like those behaviors are correctable, and they are things that you can do and say, and processes you can put in place to ensure the employee gets why they can’t do it. 

What I wasn’t prepared for is how it would make me feel emotionally, and how upsetting, how vexing it gets. And especially when you know that you’re paying above market, when you have incentive plans and 401k matches and health insurance plans because you want to invest in people. And when people disappoint you, I was not prepared for how emotive it was relative to the business hat that I’m used to wearing and not being prepared for it. And so I’ll tell you that 80% of my headaches as a new practice owner, it’s HR related, it’s managing the interactions between coworkers. 

It’s knowing when the staff members are all vying for my attention, and they’re doing what they think I want them to do as opposed to doing what’s best for the company. And also sometimes, showing each other up. It’s navigating the intricacies of the human condition and how people that are aspiring to get ahead in their careers will behave. And it’s amplified when it’s a small environment, and it’s a flat hierarchy because for an early stage practice, you got to wear multiple hats. And so front desk will be pre-cert, MAs will do check out, scheduling. And because there’s so much involved that interpersonal issues become amplified and magnified in a setting as small as this one. And so if I’d known the toll that that would take, I may have hired an MSO or a management company to do the hiring the firing part and so I can focus on the business strategy and growth.

Cheng-Huai Ruan, M.D.

And that was a necessary evil for you to feel, let me tell you. And a lot of people on this summit know exactly what you mean, but I think going through that really stimulates growth. If you were a stem cell, that will be the growth factors that’s needed to grow right now, right?

Zwade Marshall, MD, MBA

I love that analogy, yeah.

Cheng-Huai Ruan, M.D.

So I think that, I think that that lesson, and I’m a student of Tony Robbins’ Business Mastery and there’s something that I took away from it. And by the way, I’ve been a student of theirs for the third year running. So one of the biggest way I took from it is that business is 80% psychology. And if you don’t understand the human nature and the different types of humans, it is very hard to not just succeed in business, but the burnout is absolutely astronomical. Going through medical training, training where you did and I did and my wife and everything like that, I think, most residencies is that you have this sort of air of learned helplessness that I didn’t know existed until I went into private practice looking back into residency. And I think that air of learned helplessness is that things are just the way they are and there’s nothing I can do about it. 

And I see that a lot in academic institutions, and now I’m kind of revisiting it because my sister, she’s a lot younger than me, she’s in her fourth year at Columbia University Medical School. And she did her rotation at Columbia, she did another one in Harlem, and was like, oh my God, Harlem is so much better. I’m like, why? Because you don’t have this sort of air of learned helplessness within some of the other outside hospitals and stuff like that. And I’m like, yeah, yeah. 

That really reminds me of residency. And then I started talking about it with some of the other doctors on the summit. They’re like, yeah, you always have this sort of air of learned helplessness and that’s translated to the residents and the fellows, right? And same thing with financial literacy, the lack of financial literacy is basically covered over by the prestige of medicine and academia, right? And so what’s valuable for this person, finishing training is not necessarily what’s needed for this person not to burn out, to grow as a human being, to develop the relationships, right? And to make these connections. And I think, if people on the summit are listening and the only reason you’d be on this summit listening is you’ve got to understand and want to learn how to pivot from some of these things. And then I think you, as Harvard trained, MBA MD, and through the residency and fellowship, and then you coming out with this sort of Doc2Doc Lending platform, I think that’s a very passionate thing you’re doing, and so I really commend you for that.

Zwade Marshall, MD, MBA

Thank you.

Cheng-Huai Ruan, M.D.

Yeah. And so in my head, I’m like, this guy does a lot. So how the heck do you balance your life and medicine and entrepreneurship and the growth strategies and all this stuff like that, what’s your secret for you.

Zwade Marshall, MD, MBA

Man, I don’t know that I’ve mastered it at all. It’s an ongoing challenge and struggle. I have a wife and two, I have a four-year-old and a five-year-old and I have to be intentional, knowing that I’m busy, in carving out time to ensure that they are on my calendar as well because if you don’t decide that on these days, I’ll ensure that I’m at home for dinner and these days I’ll take them to school and these weekends I’ll take them to soccer practice so that I’m present and I’m there to enjoy all the milestones that I wanna be a part of. And it took reading the books about this and having my wife sit me down and say, hey, are you gonna miss it all if you get out of work and you’re on that conference call and you’re speaking with the borrowers and you go into that meeting, you have to intentionally carve out the time to be diligent around creating time for the other stuff as well. 

The other part of it is fitness. Like having that time to be reflective and a time to recharge because in our roles as clinicians and as entrepreneurs, we’re giving a lot of ourselves, a lot of mental taxing and emotional energy that’s expended. And so figuring out what is your recharge? What do you need? Do you need quiet time and just thoughtful, time to be thoughtful and reflective? Do you need to just, to run, to go to the gym and swim? They’re kind of ticks that we all have that can cause us to be drained and there are other things that cause us to be rejuvenated. So ensuring that you balance and create the time to do the things that will add energy to you. And I think the beauty of the fact that I’ve got a lending company that is related and ancillary to my day job in practice, the funny thing is Doc2Doc actually energizes me. 

It’s a different side of my brain that I use and so I don’t feel the same fatigue that I feel after I see 17 patients in the OR and then another 35 in the clinic, that exhaustion is not translatable to taking my first call with my co-founder or the bank partners of Doc2Doc. It’s a different skillset and a different energy. And so knowing when to say no to those opportunities that are gonna be draining or not symbiotic to what your primary responsibilities are, and then being intentional about the balance that you need for your personal life and for your reflective recharge.

Cheng-Huai Ruan, M.D.

Saying no is such a powerful thing.

Zwade Marshall, MD, MBA

It is. It’s so hard for us too.

Cheng-Huai Ruan, M.D.

It is, it’s hard from some personalities as well, especially if there’s on this profile, I’m a high I personality. So usually, it’s big picture and very warm, and I just hate losing connection with people and then saying no is hard, But saying no could be very liberating, especially with you, you have a four and five-year-old, I have five and seven, so I totally understand that. But yeah, these are the years that we gotta be there for our children. So I’m curious, you just said earlier that the Doc2Doc side is a different part of your brain. And I guess that’s the part where you got the business lens and the MBA. And so I think the way you approach things on the Doc2Doc side, it’s so similar to how we approach diagnosis and disorders, diseases, and medicine, right? You gotta be very holistic about it. Look at the big picture and allocate your resources to dealing with whatever is going to be at the roots of whatever’s wrong and I think that’s the way you look at finances as well. So I really want to commend you for all of that. And I mean, you’re a young guy, we are both young people, and there’s a lot of accomplishments there, but I think moving forward and moving forward together is such a beautiful thing for all of us and everyone on this summit as well.

Zwade Marshall, MD, MBA

And so, yeah.

Cheng-Huai Ruan, M.D.

Absolutely. And so I think that, in sort of discovering ourselves, because as we go through like private practice, there’s a lot of self discoveries, right? Relationships, dealing with the HR stuff and dealing with employees and allocating time and services to these things and then having that setback. As we learn through these things, one thing that I really wanna touch upon is how many people on these private practice Facebook forums are, it kind of drives me nuts a little bit, there’s just so much for like animosity between people, between the doctors and patients, doctors and not the doctors, doctors and insurance companies, right? And then it becomes this conglomerated mess where people were just kind of blaming externally the insurance and payer system. And they’re like, oh, private practice was not meant to succeed and stuff like that, which I see a lot in these forums. What do you say to sort of the naysayers, if you will, that the medicine as it is can’t really succeed, like what do you say to that? Do they just not have the lens that you have? Like, what do you think it is?

Zwade Marshall, MD, MBA

That’s a tough, tough question because there’s been a lot of changes in healthcare and medicine over the course of the last five years. If you go back 10 years, it’s even more there as well. And so healthcare in the US has changed incredibly in recent past relative to the previous decades. And with that change comes a lot of discomfort for many of us. A lot of it has been changed that’s not been better for physicians in practice. And I understand what makes someone gripe, someone in private practice like we are, gripe comparatively to the hospital-based physician in a sense that there are intentional lobbying carve-outs that discount the work that we do in private practice and elevate the work that’s done in a hospital. But we’re in the community with less resources, spending the time, taking the calls, and yet the same CPT code in this setting is discounted relative to that setting. 

Same brainpower, same treatment plan, but just less reimbursement. So I get it. The thing I’ll say though, is that there’s, the beauty of the American system, the American ethos period, that innovation is always rewarded. And instead of griping about the facts as they are, it’s finding the way to innovate around it, right? The advent of telemedicine has been huge as folks try to get access to see more patients outside of their immediate geographic area and incorporating telehealth within a practice has been transformational for many practices. It’s realizing that you can vertically integrate upstream to make that visit that’s discounted, have more value by adding other products to the actual encounter. 

So if there, some many states now have medical marijuana or CBD licenses and if you’re in the pain space and you have a retail part of your practice that has a medical marijuana card and CBD products, now a visit that was gonna be reimbursed 120 bucks is now worth $185. If you have the wherewithal to think about looking at your practice as not just one thing or not just clinical medicine, but what are the other value propositions that I offer that’s within my purview, because you don’t wanna go outside of your scope of practice either, that can be monetized, the flexibility that we have in private practice, it far exceeds hospital-based doctors and hospital practices as well. And so, because we have that freedom of choice, freedom of practice, freedom of scope, the ceiling is a lot higher and so we need to innovate outside of the box that we’re forcing ourselves into if we just discussed the insurance reimbursement, the way the justice department goes after private practice docs compared to hospital doctors. Those are all things that we have to face, but ultimately, is a higher ceiling where we are.

Cheng-Huai Ruan, M.D.

Yeah, I absolutely agree with you. Talk about vertical integration. So it’s a lot more applicable within the private practice space which far out exceeds the difference in CPT reimbursements from the insurance companies, between the non-facility fee and stuff like that. So when people are looking at singular items, they’re comparing apples to oranges and they have no idea, and that’s what creates a massive amount of burnout but you know what, that’s also, that thinking also creates poor spending behaviors for physicians as well. And I’ve been guilty of that. First one to raise my hand, I’ve been guilty of that. Until you see, until you sorta open things up and see a whole lot. In fact, in this summit, we have an entire day that’s dedicated to integrative health and health coaching in the insurance market and a health coaching is our, now, taxonomy as of April 1st, 2021, it’s seen as a specialty within CMS. 

So there’s actually reimbursable events now. And one of the ones that we’re talking about is chronic pain management in groups and in individuals as well as that’s reimbursed virtually which is scalable. So stuff like this are just some of the things that happened because of incident. We can say, maybe since coronavirus, we’re able to get reimbursed on telemedicine, we’re able to do things in groups. There’s like 153 codes that we can do in telemedicine now that used to be only one-on-one. So there’s a lot of changes that were required because of the pandemic. And as you said, but as this has changed a lot in the last couple of decades, far more compared to the 200 years before the last couple of decades, because of technology, because of connectivity and because of the expectations of the public are quite different because of social media, right? 

And then doctors, for the first time in history, can be discounted based on Instagram posts or Twitter posts or something like that, right? Which is just now when we’ve seen, this is like foreign. And so I think if I were to put what you just said in one word is you got to learn to pivot, pivot is the actual word, right? And then roll with the punches, and that’s what this summit is designed for. So I think, and our time’s about up, but I’m gonna ask you kind of one last question about just you in general is, where are you, Dr. Marshall, five years from now? Like just think with your lens, five years from now, where are you? Where’s Doc2Doc, where’s your practice?

Zwade Marshall, MD, MBA

Sure. I think Doc2Doc would be offering a comprehensive suite of financial products to our borrower base. We’ll continue to grow the relationship that we have to create that borrower stickiness, right? We benefit now from our physician base coming back to us to ask about student loan revise, about medical practice loans, about credit cards, about practice buy-in, and those are not products that we currently offer that we will be offering in the very near future. And so we will be a comprehensive solution for the physician that needs some financial product at the right time, and we’ll help them navigate that process. On a practice level, I think I’ll certainly have several more locations. 

My goal is to create my reach and footprint as a practice, I think there’s a lot of good work that I still have left to do. And I enjoy the growing of a business, and over the course of the last nine months, I’ve seen my practice grow already and adding a surgery center to it and filling those slots has been incredible to see. And so with it, the next chapter is managing other physicians and bringing on partners and storming the shores of Normandy by going head to head with some of the big players in the marketplace and beating them at their own game because if you’re nimble, if you’re patient focused, there’s a lot that you can do to kind of create value for the customer experience and deliver a good service where that competition also excites me.

Cheng-Huai Ruan, M.D.

Well, that’s absolutely wonderful and I wish you luck. So where can people find you? Where can people find Doc2Doc to learn more questions?

Zwade Marshall, MD, MBA

Sure, thank you for asking. It’s doc2doclending.com, www.doc2, the number two, doclending.com. And the application is online. It’s a three minute physician-friendly application. We get outcomes in terms of a decision and an approval within minutes. And we welcome the borrowers to speak with one of our physician team members. And we’ll help navigate the process and funds are dispersed within days. So we’ll welcome anyone that comes in from this summit as well. And I’ll be listening to some of the talks also. I think that chronic pain talk that you mentioned, you bet I’ll be consuming that one as well.

Cheng-Huai Ruan, M.D.

Absolutely, well, thanks for being on. And for those of you all listening, the link is with the description in this video, go ahead and click on that and it goes directly to the page where you can sign up. And it’s so cool to put in something like financially and not talk to a banker, but talk to a doctor. That is the coolest thing. I absolutely love that. So thank you very much.

Zwade Marshall, MD, MBA

Thank you.

Cheng-Huai Ruan, M.D.

Thank you for being on. I appreciate you.

Zwade Marshall, MD, MBA

Thank you, Dr. Ruan.