Tea Nguyen, DPM (00:54.488)

Welcome to the podcast. I have Dr. Maria Bernal here, an endocrinologist who practices telehealth, coming out from Florida, and she's also multi-state. So welcome to the podcast.

Maria Bernal, MD (01:06.434)

Thank you so much for having me here. I was listening to your episodes for quite some time already. I found you through one of the Facebook groups and it has been very nice to have a space for specialists in the DPC model to learn from.

Tea Nguyen, DPM (01:23.958)

It was so necessary, you know. A lot of this came through the co-founders of the Direct Specialty Care Alliance, which is Dr. Diana Granita and Dr. Lara Kenny. And I just tagged along. I was like, I love whatever it is you're doing. What can I do to help? Because I was talking about direct specialty care. And there are so many different ways we can do this. Everyone's story is worth telling. So I'm so glad that you're here because you've got a unique niche. You have a telemedicine practice and

It says that you started fresh out of fellowship. That's insane. And the stuff that I want to get into today is really like, how did you get to that? And then now operating in multiple states. And also like, how did you grow it? So let's start from the beginning. What did life look like for you before direct care?

Maria Bernal, MD (02:13.24)

Well, I was very indecisive trying to find my way when I was in fellowship and they start and the technology is a two year fellowship and it feels like shortly after you start because people usually start looking at contracts during the second year, right? So it feels like six months into fellowship and you're already being asked the questions by your attendants, what do you want to do next? And I was like, Okay. I only knew that I could see the frustration of my attendance in academic medicine, that they were not happy. I trained where you only had twenty minutes for patients for follow ups and forty minutes for new patients. And endocrinology you need a lot of help before the patient gets to the room, downloading insulin pumps, things like that. So it was actually effectively fifteen minutes max with the patient. And obviously I couldn't practice endocrinology. How I won is I was always running late in my clinic, in my fellow clinic. I was like, I don't want to do this. I love what I do. I love being an endocrinologist. I have no doubt about that. I did medical school in Venezuela, so I felt that it took me more years to get into residency and finally fellowship. It's like I have invested more than fifteen years of my life in getting to this point. Of course I want to pursue this. But it didn't feel fulfilling.

Or that I was doing my best. I felt that I could do a much better job if I had more time to do so. And I just started looking on Facebook groups and probably if there were Chat GPT at the time, I would be like, Hey, what do I do? But I was just so confused. I was in private practice, and we have a mentorship program in my fellowship. And the idea that I got a private practice was even worse, the time constraints. That it was like twenty plus patients per day. So I was like, okay, the options are academic medicine. I also wanted to become an obesity specialist. I have been practicing a healthy lifestyle for many years myself. So I knew that that was something that I wanted to pursue as well. So I was like, should I focus on that and then put a break on it? And I don't even know how, but through Google search I came across DPC.

Maria Bernal, MD (04:36.994)

And then I was accepted at the Facebook group and I heard about the podcast My DPC Story. And the very first episode, scrolling through many of them, because most of them were with primary care physicians, it was Dr. Nicole Harkin, a cardiologist. And she was sharing her story how when she decided to open her practice, COVID hit, and she had to switch to a telemedicine only model.

And that was enlightening for me. Number one, knowing that a specialist can do this. And in my mind, the number one thing you're training in medicine is cardiology, physical exam, and auscultation. I was a COVID baby. I COVID hit during my first year of residency. So I knew what seeing patients through telemedicine looked like. In my fellowship, we served a VA that covered a big, a large area. So I was also exposed to telemedicine.

w in my specialty. So it was enlightening. It was like, okay, this is an option for specialists. It can be done via telemedicine. It will allow me to start without a huge capital. And that's how I decided after listening to a podcast episode.

Tea Nguyen, DPM (05:53.954)

So dangerous listening to a podcast. You might actually change your life.

Maria Bernal, MD (05:57.502)

I know, I know.

Tea Nguyen, DPM (06:00.046)

Awesome. So out of your training, out of fellowship, you just went all into your telehealth practice. Is that correct?

Maria Bernal, MD (06:08.618)

All in I had my I started doing moonlighting with a telemedicine company to see what it looked like outside of fellowship and making sure that I felt comfortable with the model before I jumped to open a practice of my own, registered ALC and believing that that was a model for me. And I was like, Okay, this is totally doable. I started creating my accounts with an insulin pump.

reps, CGMs, continuous glucose monitors over being able to download patients' glucose data, starting to get used to the whole thing of how endocrinology was gonna look like with me taking control over those things that were usually taken care of when I was in the hospital as a fellow. And then the big other question was like, okay, I need money to pay my bills. And I knew that a business takes time. So I decided to start looking into locums. And

I still do locums to this day and has been what has allowed me to sustain myself financially while going and practicing right fresh out of fellowship when you don't have any capital.

Tea Nguyen, DPM (07:19.448)

That's hard. That's definitely a reality a lot of doctors need to realize there needs to be some kind of financial runway because it takes time to grow this practice because you're building each and every individual part, you're building the funnel, the marketing component, you're building the skills to sell your services. And doctors are going to want to know as you have this job for financial stability.

Does that interfere with you not taking insurance in your private practice? Or do you still take some private practice insurances? What does that look like for you?

Maria Bernal, MD (07:58.902)

100% cash pay. I don't work with insurance at all. I don't accept any insurance. I still see Medicare patients, so I'm with locums. So I'm enrolling in Medicare, which means I cannot see Medicare enrolled patients in my private practice. But no, I'm 100% cash paid and it has been like that since the beginning. I knew I didn't want the time constraints. And my whole purpose was, yes, I I know I need a financially sustainable business because

I wanna be financially successful as well. And I think one of the things that we have to retrain ourselves is that in medicine we are trained not to charge for our time, for our knowledge, for our expertise. And I feel that we need to be more comfortable with that. Like us we don't have to hold that standard for any other special for any other profession.

If you have a lawyer, yes, you expect them to charge you for your time. If you have a marketing team, yes, you expect to charge for your time, your medical assistant, anyone who works with you. And we are the same. But my goal, my ultimate goal was for being able to practice medicine and enjoy being a physician. Being able to find that balance. And I knew that that was non negotiable with insurance. So that's why I decided to go all in.

Having a financial plan is the most important thing that one can have when making this decision. And that looks very different for everyone. So you have to be mindful of your reality. I didn't have kids. I was married at the time that I made the decision, not anymore. But that really helped. But I didn't rely on that. That's why I also wanted my in

So I could make sure that Apex could also grow epically. In endocrinology, if I were giving everyone testosterone, I probably could grow very easily and quickly. But that was not the type of practice that I wanted to build. I opened a Facebook group for people interested in doing telemedicine because I felt that telemedicine had its own pros and cons.

Maria Bernal, MD (10:15.724)

The fact that you don't have enough is not every patient feels comfortable with that. How you market yourself, you only exist on the internet. So you have to heavily rely on that for your advertising for captured patients. And it has been great, honestly, learning from other people, what they're doing out there and and and trying their best to thrive in the telemedicine model.

Tea Nguyen, DPM (10:39.448)

So tell us about what your marketing strategy has looked like over time. What works? What was a total waste of time for you?

Maria Bernal, MD (10:49.838)

So the number one mistake, and I think I heard you in one of your podcasts talked about this, is having the belief that being a good physician is enough. That was my number one mistake. because I graduated from fellowship and I'm like, I know I'm good at this, I like it, I'm passionate, my patients love me, I'm gonna open a practice. And then you assume that that's all you need, being a good physician, and that's what we have been trained for. So

My first year I think I realized that that wasn't enough. I opened I graduated in July twenty-fourth, the website launched on August 24. So very early, still finding myself and within direct specialty care. Now I'm training myself in what I'm starting to call the CEO mentality. Not only because I don't want to be a good physician, but because having a business cannot solely rely on that.

That's just not gonna make the API successful. So I started to work with a marketing team who is helping me with optimizing my search, my SEO. That has been working and I started recently months ago and I have seen a little bit of a change in trends. I was also using Sock Doc. I don't know if you have heard of that platform before.

Maria Bernal, MD (12:14.88)

It was very pricey. I stopped doing it because it was very expensive. You pay per leads. And I would say in my case, about thirty percent of the patients were actually following through and having the appointment because most of them would cancel when they saw that I was a cash pay practice. And if you go through the website, when you go to my profile and about it, yes, it says that I didn't accept insurance. But the website was very big on selling.

Finding a physician without insurance, scheduled for free. So I felt it was also misleading. But it helped me to grow reviews because again I'm coming fresh out of fellowship, right? So I don't have a name. That was my particular challenge. But it was also my choice. so I I would say I almost paid for for like having a name out there and existing on Google Business Profile and people searching my name and looking at reviews I could

Maria Bernal, MD (13:10.018)

Tell them what it felt like to be my patient. And now I'm also starting to work on Google Ads.

Maria Bernal, MD (13:20.448)

I have heard a lot of mixed things and advice about Google Ads. Some people say they don't work for specialty care. I don't agree with that. I just feel that you have to be very savvy when making your Google ads that you're tapping into your patient's pain points. And for being able to do that, you need to have some questions answered. What is your ideal patient number one? Because then you know who you're targeting that app for.

Why is that patient gonna choose you? And what makes you unique? How you can address and treat that patient. Building the Google ad around that, I haven't had it in my fourth month I got the Google ad. And I would say I'm starting to break even after how much I have spent after gathering the fourth patient. Still a bit negative. But I'm very hopeful in the fact that

I believe in the butterfly effect. Some things you might not see in the number right away when you make the investment, but to think long term, I'm also learning from this experience. I use my Google ads as a constant teaching experience. I'm not a CEO. I don't have a background in business. I need to learn this. And learning takes time and money sometimes. It's training. It's like the way we invested money and time and became physicians.

So my Google ads have taught me how to tackle certain things, search words. For example, removing the word near me made a big difference and having less patients calls for believing that I was a physical practice and really targeting people who are looking for telemedicine and having a big decision from the comfort of their house and the convenience and the flexibility of it.

Yes.

Tea Nguyen, DPM (15:14.254)

That sounds pretty right on track because there will be people who say Google ads don't work, but there's a strategy and they're missing that component is the strategy. It's not just I exist, come to me, I have a medical degree. It really comes down to what are you offering that's different. And you just right on the head, exactly right. Because I've done both myself and I spend a lot of money learning what didn't work.

Which means I was a little bit closer to knowing what did work. So it's all a learning opportunity. So I want to make sure the doctors realize that you don't know what's going to work for you until you do it. So that for sure, I think is always worth your time for even direct specialty care practice that does not take insurance. Because people are frustrated. They're looking for solutions and they think the only option is going through their insurance until they go through it. And they have a mediocre experience. And they're like, is that really all there is to it? And we're here to say, no, actually, there's one more thing. You missed this thing that we have. So I'm so glad to see that you're out there, you're proactively learning stuff that none of us learn. Nobody taught us about Google ads. We didn't have AI. Like we were toughing it through. But now we've got so many resources, there's really no reason to not succeed in this model, I believe.

It's just a matter of admitting to yourself that you gotta learn a few more things, that your degree is not a marketing degree. So I love that about your growth in your practice. Cause now you're kind of moving into a year two of your practice. Right. Are you where you want to be?

Maria Bernal, MD (16:58.71)

Not even close, but I have in my mind clear that I have this amazing thing in my hands that is apex that can grow in so many ways. I believe there will be a point in my career where I would want to see patients. I enjoy seeing patients so much and I still get that part by doing locums that I know I would probably want to transition to a physical practice.

So that is something that I also found out by doing telemedicine 24-7. It's like, no, I actually wanna see my people in person. I enjoy that. Apex when I started growing, I wasn't sure what most of the patients were gonna find me for. triple bore certified, so I bought some bore certified in obesity. I would say

Probably fifty percent of my patients I do weight management. So my next acquisition in my practice was hiring a ten ninety nine, so a con independent contractor is a health coach who helps me with teaching my patients what the lifestyle looks like for them.

And and I'm I feel that as you do this, if you approach it with an open heart and a creative mindset, you will find your answers of what might be your next steps while you do this. And I really like what you asked me about the marketing strategy because I didn't have one at the beginning. And then I realized it needed one and I'm still navigating that. And it's that's why I know that I'm not even close to where I want to be. But it's like an amazing throat.

And I plan to continue to find my answers along the way.

Tea Nguyen, DPM (18:47.118)

Well, if you didn't start, you would still you would be pushing out the inevitable, right? If you didn't start two years ago, you just keep moving to Target. So I'm glad you did the thing that seemed like impossible, really. So I'm curious as to what your model actually looks like. I saw on your website, which is beautiful by the way, it was created by Saw, which she did my coaching.

website also. There's a style and I looked at it and I was like, I bet just Sab did that. And of course I scroll down. She's got a beautiful style. So your website is gorgeous. And I saw that you offer a fee for service or a la carte and a monthly membership. Is that are you happy with that? Like how do you see your evolution in your practice?

Maria Bernal, MD (19:36.012)

I like it and I was just at the DPC summit, which I it was my first time, and it corroborated something that I had a gut feeling about. So with specialists, I feel that there are a lot of patients who need a second opinion. I'll give you examples of patients like cases that I have managed in my practice. The patient was incidentally found to have a pediatric adenoma on MRI after he went to the emergency room.

See neurologist right away. It was a macroadenoma. The patient needed surgery. But they need the endocrine pre-operval for the whole pituitary access. Patient is referred to endo has to wait six months for seeing endo. it's not urgent, but six months is quite the way, but more so when you're concerned, like, okay, this is something new. I didn't know I have it, so I went to the emergency room. The neurosurgeon told me I need surgery, I have never seen a neurosurgeon before.

And then all of a sudden I have to wait six months to see if this is actually causing any other issues or even knowing if I need surgery, because maybe there's a prolactinoma that can be treated medically. That patient came to see me. It was a non-functioning adenoma, so it needed surgery based on the size. And I did the pre-operal, but I also told a patient, hey, you know what? I want to refer you to the university hospital so they can see you while you're in patient.

They can run cosentropic syntax, like all the things that you would want to do in a controlling patient environment. So that's when I see that the value of having someone who is accessible with a flexible schedule can be very useful. And then the patient can transition to even other services if needed to. And that was one of many examples of patients who come to see me as a second opinion.

I decided to keep the fever service and the membership. Also, not every patient and I have seen a lot of mixed opinions, so we'll love to hear what your opinion is about this on Facebook groups like no, you should try to have everyone on membership. I see ladies for osteoporosis that can perfectly see me once a year. I don't feel that they have to make the investment of paying for a membership when I'm not actively managing something that needs follow up every three to four months.

Maria Bernal, MD (21:56.756)

So I'm very open about patients don't have to choose before they see me. I help them choose. And I tell them, is this something that we would need more frequent follow-ups? I should probably be better at setting boundaries because my membership is followed up every three to four months, and sometimes I find myself even sooner than that. But yes, so I help them decide what this journey is gonna look like.

For example, GLP management, absolutely. You need to titrate us, I need to be checking on you, side effects, weight loss, laps, diabetes, thyroid, even more so if thyroid is in pregnancy, that is a big one that I'm like, you have to be on a membership. We're gonna be doing laps every six weeks. Other than that, I usually let them choose.

Tea Nguyen, DPM (22:46.988)

Yeah. I think when you're early in your practice, you're just collecting numbers. You're just trying to see who's actually coming through and what feels good to me and what's working with my ideal patients. So for specialists, I think that's kind of where we get to play a little bit where we have so many different things to offer. You know, for me as a podiatrist, I can barely medically manage anybody, to be honest. But if I do, you know, it's there. I'm usually doing hands-on work.

So they need to see me once a month, or I'm treating something that has an endpoint, a surgery. You know, you don't need to see me all year long. So because of the things that I enjoy, it makes sense for me to have the membership, the a la carte, and small packages. And what makes me the most money are the small packages that have an endpoint. If they have nail fungus, that can be treated without medication, without long use of medication, for example. And a lot of people are looking for that. But I wouldn't have known that if I didn't

make the offer and see what showed up. So for financial viability, I always like to make the offer to my doctor clients to consider having one specialized package that you can sell at a very high value, high ticket, an expensive one. So if there's an endpoint, like let's say you had a patient who let's use OBCD, there's an endpoint. They need to lose 100 pounds, right?

There's gonna be a short period of time where they need to get back on track and do things routinely. And then after they're stabilized, then they can have a back-end offer into the lower monthly membership where you retain that revenue. So for me, I like that model best. And I know that's very different from the DPC model, where it's a monthly membership, it's low, it's affordable, you know, it's for whatever shows up, it's there for you. And I like that too. But for a specialist like me.

I just have a lot to offer. I'm like a buffet. So and it works for me. I know what I like. And once I start learning what I don't like, I do less of it. I just talk about it less. I just don't put ads out about it, you know? And so I try to be there for my community. I try to be very transparent. And this is just how my brain works. I can't I don't see myself having one membership because I I float around too much. I do too much. I offer too many things and that's fun for me.

Tea Nguyen, DPM (25:07.576)

But if you want to simplify your practice, that's where DPC really shines, where they just have the one offer. The one offer is the monthly access. That's all there is to it. So you can do whatever you want, is what I'm saying. It doesn't matter. It's what feels good to you for the moment because you have a kid, your life looks different. You go through a divorce, your life looks different, right? You go through some kind of life change, life just looks different. And I for me, I don't think I can do memberships for twenty years. I can do it for a couple years.

So there's no wrong answer.

Maria Bernal, MD (25:39.266)

It makes sense and I I didn't think about that, but that is a I'm thinking and I do have definitely cases that are more labor intensive at the beginning and then they just need less frequent follow ups. I ended up creating two memberships and one of them was like this because I realized that whenever I was managing metabolic disorders, specifically GLP one, I was checking in so frequently with the patient every two every four weeks before increasing the dose.

There was no way that we're gonna wait for three to four months. I and I also didn't wanna wait because then I had the opposite. I had some patients who I would see them in the next follow-up and it's like, yeah, I stopped taking the medication because it was throwing up. It's like, no, could have told me we decreased the dose, try to understand what happened, what the trigger was. And that's why I incorporated the health coach as an add-on and he's someone who is like checking in with the patient more frequently and is very well trained in when to let me know if anything is happening.

that I need to step in and maybe have a more frequent follow like a sooner follow up with the patient.

Tea Nguyen, DPM (26:39.392)

Yeah. So we were all learning what works. Like what works today is gonna look different next year. It's gonna look different with AI tools on the market, with competition, more doctors showing up, or non-doctors showing up even, right? So the landscape continues to evolve and our practice will too. So I know the doctor's listening and they're super excited to understand that telehealth could be for them. Yes. What would you say to this doctor about not taking insurance? What

Key things should they be considering before they take the dive out of insurance?

Maria Bernal, MD (27:13.144)

So I would say I will definitely offer them to also join the DPC telemedicine group. It is our Facebook group with people doing telemedicine or interested in telemedicine. And I credited that community because I felt I had a lot of questions in telemedicine when it comes to, for example, I do testosterone, which is a controlled substance. What about controlled substances across state? It's very different. DEA regulations, licensing across states, contracts across state.

Even the LLC, for example, I practiced, I started with New York and Florida. In Florida you can have an LLC, but in New York you need to have a professional LLC for practicing. So when you start crossing state lines, you have to comply with every state rule and it has its own implications that are beyond the contract, that about the company structure. People think just about the license. No, it is your company structure, the licensing.

even their account with the labs, with imaging centers. It is number one, it is doable. By no means I'm trying to say this is too hard. No, no, no. Telemedicine offers great pros as well. You just have to be mindful of this other reality. So you can create a model, a practice that is compliant with like what you see for that model. And I learned a lot there. We're already like two hundred and fifty plus members and it's very nice to get to know people.

We're doing the same, for example. I had a member who joined a few months ago and I just finally met him at the TPC summit and he opened after joining the practice. He's a rheumatologist, and who was telling me, has been open for two months and I have three new patients. I was like, You're doing great, keep it up. so number one, it is doable. I spent a lot of money in finding a lawyer who had expertise in telemedicine and had different opinions on this. It also depends how you want to run your practice.

Some people are now even drafting contracts with ChatGPT and Cloudy. I don't do that. I didn't do that. I wouldn't recommend that. It is of course going to be cheaper. But I made mistakes. For example, the first lawyer that I consulted was recommended to me by someone who had a physical practice in one state, one city. And this person told me, Yes, I can help you draft your contracts. Here they are for New York and Florida.

Maria Bernal, MD (29:37.824)

Later on, I had questions about my DEA license in New York because by reading the law I felt there was some mixed opinion. So I ended up having someone who is a talented medicine lawyer specialist. This person charged me more than $10,000 of RAM just to answer that question. But that person also made me realize that my LLC that was opened in Florida was completely illegally structured in New York. She told me you're meeting the law, you're meeting the requirements.

law requirements by being a physician who owns 100% of the LLC. But I ended up changing my company structure to a professional LLC. So just to give you an example, I wasted time and money by paying two other lawyers before trying to draft my contracts and things. And I ended up paying someone more expensive but that knew how to navigate medicine across different states, multiple states.

So that's what I would recommend based on my experience and also on my level of comfort with risk. I don't wanna risk my license. I wanna do this in the right daylight and comply with anything. So finding a lawyer that is a specialist in telemedicine I would I think is important. so that they can help you with the caveats of the small details when it comes to that.

And start marketing. It is never too early. You can start by social media, going to networking events, starting to work in developing that CEO mentality. Because I feel it is something most of us visitors don't have. And that regardless of which model you choose, physical practice, hybrid, telemedicine.

Regardless of the specialty or primary care, you need to have that CO mentality for growing a business. And that is something that can be trained, can be learned, and that you have to find your way, your level of comfort with it. So with a practice that only exists online, you really have to cover a wide area. So networking, LinkedIn, Facebook, Instagram.

Maria Bernal, MD (32:02.722)

Finding those channels that can help you grow exposure are non-negotiable. I didn't like social media. I had the completely wrong idea that I could go without having to use it. And it's just not feasible. It's and I and now I made pieces with it, right? It's just me advertising my product, my services, and my knowledge. If I don't feel comfortable

Explaining what I do and how I can benefit others, how can I convince anyone? How can I help someone understand that I'm a good choice? That direct specialty carries a model that serves them. So yeah, those will be my advice.

Tea Nguyen, DPM (32:46.574)

That's awesome. You're so right. The EO mindset is a whole nother personality. You should say. And it's learnable most of all. You know, we don't learn this in training, so we learn it in real life. School of hard knocks, they say. Awesome. I appreciate you being here with me so, so much. Where can doctors find you if they want to connect and learn more about how you built your telehealth practice?

Maria Bernal, MD (33:13.568)

Yes, so a few things. On Facebook we have a page for the practice, Apex Endocrinology Health LLC. My email, I'm open to helping anyone who needs anything, and I mean it. I genuinely made this decision because of a podcast. So this is something that we don't have any book to go by. We need to connect and even learn from others. My email is Doctors abbreviation, so drbernal@apexendohealth.com. My Instagram is drbernalendocrinology. The Facebook group that I created is DPC Telemedicine Group. And I also have people who are not doing telemedicine. Sometimes they just wanna expand. Like, okay, I'm in Florida. What if I open telemedicine in another state and I start growing my practice away? And I opened a newsletter.

It's a new project called the Cash Pay MD to teach people about telemedicine cash practices. And I tend to share something that I made, a mistake that I made, something that I tried that didn't work, something that I'm trying now, and specific recommendations. For example, hey, this is my lawyer, telemedicine specialist, and no conflict of interest, it's just specific things that help me.

For example, finding malpractice insurance when you're one hundred percent telemedicine practice can be challenging. Not every carrier does telemedicine practices. So sharing those advice and resources that I found along the way.

Tea Nguyen, DPM (34:53.28)

Amazing. I will put all that information down in the show notes. Thank you so much for being here with me today.

Maria Bernal, MD (35:00.248)

You're welcome and so nice to meet you. I really like your podcast.

Tea Nguyen, DPM (35:04.204)

I appreciate that so much. So nice to meet you too. Thanks for listening. I will catch you all next week. Take care.

Tea Nguyen, DPM (35:13.986)

Thank you for listening to the Direct Care Podcast for Specialists. Remember, you always have the power to choose. So what will you be choosing today? Wishing you peace and possibilities.