Interview with Dr. Brook Choulet
Is it possible to establish a concierge practice while still in training? Dr. Brook Choulet is still in her child and adolescent psychiatry fellowship and runs a growing practice in Scottsdale Arizona.
Brook is the founder of Choulet Wellness. She completed her medical degree at the University of Missouri Kansas City’s rigorous six-year BA/MD program. Then she pursued training in General Psychiatry at the University of Arizona College of Medicine at Phoenix.
She is currently in her last year of training in Child and Adolescent Psychiatry through Creighton University’s fellowship program in Phoenix, Arizona.
Following in the footsteps of her mother and grandfather, she will be a third-generation adult, child, and adolescent psychiatrist. She built her own business during her residency training and began to expand and hire other practitioners while still in fellowship.
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How to Establish a Concierge Practice
Brook starts by explaining why she started her concierge practice. Then she explains how she boot-strapped the practice, starting with just one associate, while still in residency. She also explains the basic steps, from forming an LLC to finding her first location to see patients.
Just go for it… If I can do it with very little experience… then I have no doubt anyone can do it at any stage of their career. – Dr. Brook Choulet
We also discuss which other specialties would work best in a concierge model like hers. She runs a cash-only practice and is funding the growth of the business organically. And she explains how this model eliminates most of the headaches of typical employment.
Growing Her Business
Brook has hired therapists and wellness experts to meet the needs of her patients and clients. She started by sharing office space and has now moved the business into a dedicated office. The practice is now expanding to a second location.
Summary
If a psychiatric resident can open a concierge practice, certainly other physicians should explore this type of practice. It generally provides for a more balanced lifestyle that can also be quite lucrative. As the physician shortage grows, and insurance deductibles increase, patients will be more willing to use a direct-pay model to meet their healthcare needs.
NOTE: Look below for a transcript of today's episode.
Links for Today's Episode:
- Choulet Wellness
- Brook Choulet MD Website
- Dr. Brook Choulet's LinkedIn Page
- Entrepreneur and Business Owner – Interview with Dr. Mike Woo-Ming – 019
- How to Help Committed Colleagues Heal the World – 186
- Can Meditation Offer Help for Burned-Out Physicians? – 172
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Transcription PNC Podcast Episode 210
Want to Establish a Concierge Practice Before Finishing Your Fellowship?
Interview with Dr. Brook Choulet
John: When we as physicians become bored or frustrated with our practice or burnt out, our first instinct might be to leave clinical medicine. But we should stop to consider whether a different boss or maybe different partners or a different department in a big company or a different corporation or practice setting itself might be a really effective alternative. I know we talk about nonclinical careers here, but definitely non-traditional practice is another alternative. So, today we're speaking with a physician who has created a practice that avoids many of the traps of corporate medicine while she's still in training, if you can believe that. So, Dr. Brook Choulet, welcome to the podcast.
Dr. Brook Choulet: Thank you so much for having me here today.
John: Once I heard your story and I was talking with Brent Lacey, one of my podcasting friends, I thought this is really interesting because the things that you've implemented, I think are very instructive for many physicians who maybe feel trapped. And I thought, "Wow, this will be very good to share". Before we get into the specifics, why don't you tell us a little bit about your background and education?
Dr. Brook Choulet: Sure. I grew up in Cleveland, Ohio. And after many winters, my family moved to California. I finished high school in California, and then I ended up going to Kansas City, Missouri for the six-year bachelor MD program. My mom had actually done the same program and she really thought it was valuable and a good use of time. So, I was excited to head out there. I spent several winters again in Kansas City, and then I matched out in Phoenix for adult psychiatry residency at the University of Arizona College of Medicine, Phoenix. I did three years there, and then I transitioned to a child and adolescent psychiatry fellowship. And I'm currently in my last year of fellowship.
John: Awesome. That should be keeping you pretty busy but I think you have some other what we might call a side hustle or side gigs that you've been doing. Why don't you tell us what those are?
Dr. Brook Choulet: Sure, just to name a few. The first thing I did when the pandemic hit was I used some of that downtime when the clinic was in transition and residency to become a real estate agent. And that initially took me about a month and a half to complete that process and get my Arizona real estate license.
Then I started kind of thinking about what I wanted to do with the rest of my life after I was done with training and really decided I wanted to build a practice where things were on my terms and not the insurance company's terms. And I could actually spend time with my patients and spend valuable time hearing what was going on, hearing what their current life situation is. And that really led me to build this concierge psychiatry practice out here in Scottsdale. I started working on that in residency and it kind of took off from there.
John: Help define for us what concierge psychiatry would be?
Dr. Brook Choulet: Sure. There are a lot of different definitions of what concierge medicine is. I think to a lot of people, they might assume that it's a membership-based practice where you pay a retainer or you pay a certain monthly fee for access to the clinic. I think that psychiatry is such a unique field where you really have to connect with the person and the physician that you're going to. I wanted to avoid that model and I ended up just choosing a fee for service hourly rate model to really give not only the patients flexibility of where they wanted to get their treatment but also to make it more approachable for many patients who might struggle with the thought of a large retainer or membership-based fee.
John: Okay. That's awesome. And listeners, I want to make it clear. We are not going to go back and talk about real estate today. We're going to be talking about this aspect of concierge practice and maybe the general topic of just designing a practice that really meets your needs as a physician, rather than being sucked into corporate medicine, I guess, as some of us call it.
So, your concierge model is you have an hourly rate and you deal directly with patients. What about the payment? Is there any middleman in that payment model or not?
Dr. Brook Choulet: The clinic collects payments directly through credit card, we use Square and we use an EMR system where actually Square is integrated into the EMR system. So, there are actually no manual payments being run. You can set up a service, set up the price for it. And an hour after that visit it automatically charges for that service fee. And it really cuts out even anyone in the clinic having to run cards.
John: There's no billing per se or anything like that. Can patients take the information and then file a claim with their insurance company if they have one?
Dr. Brook Choulet: Yeah. There are a couple of companies out there. There are reimbursed five, better claims and they can assist kind of expediting that out of network claim, but that is up to the patient to do that part. The clinic is just responsible for providing that superbill.
John: That sounds like how it was maybe 30, 40 years ago when we would just have a paper, superbill and we would give it to the patient and say, "Well, this is what you owe us". And going through this, the rigmarole of trying to build these days, oftentimes even a small practice has hired like two or three people just to do that.
Dr. Brook Choulet: Yes, that is exactly why I looked at several different systems. And I really wanted to make things as efficient as possible, both on the clinic end and for the patients, because even nowadays I get invoices from outpatient clinics that are coming in paper mail, it has some access code. It wants you to go to a website, enter it, manually enter the payment. And for both the clinic and the patient, that seems really inefficient.
John: From what I know a practice like that is, like you said, it's more efficient and I use the word parsimonious, but you don't have to have a lot of staff to run it because you're spending the time with the patient generally and you have maybe a little bit of support. Tell us what that practice actually looks like in terms of staffing at this point.
Dr. Brook Choulet: We actually just went through a little bit of a hiccup, where the one staff we did have decided not to answer the phone and that's a pretty critical role in a clinic where we are providing such a high level of service. And so, we're currently in transition, but we have new staff starting on Monday. To answer your question, other than the physicians and the therapists that are talking directly to their patients, we just have one other staff member at all times.
John: There was a model in family medicine a while back, I forget what we called it, but it basically eliminated all the support. And there was actually a physician who was answering the phones, doing the billing, and running the EMR, but it was very limited and he spent basically 90% of his time seeing patients and didn't have to leave and have a receptionist, even though the office was open four or five days a week. There are ways of doing this in an efficient way that still serves patients very well. right.
I feel like there's still a lot of unknowns in how you put this together. How did this come about? You were in your residency, now you're in your fellowship. Maybe walk us through the steps, the "a-ha" moment, or what really inspired you to do this. And then what were some of the smaller steps in making this happen?
Dr. Brook Choulet: Sure. The smaller step is kind of what happened initially. That's building an LLC, getting a tax ID, opening a bank account. Kind of just some of those basic necessities of starting a business. Then you have to have your malpractice in place, consult some attorneys to figure out a business structure since there are so many different ways to structure a business. I think that's really critical. Without that step, you don't know where to go and don't know how to hire people. So, I think that was a big step.
And then really how this came about was almost random if you want to say. I had already started the practice myself, just seeing patients. I have an office and executive suites, very low overhead, just kind of doing my own thing. I was getting a facial and talking to the girl that was doing the facial about how unhappy she was in her current location. Just hearing some of the struggles she was going through. And I was talking to her about my desire or passion to build a large wellness center here.
We started talking and I kind of offered her a position on the spot. I'm like, I think it would be great if you join the center. I am not sure what I'm building yet, but I think you'd be a great addition. So, that's really the moment that put almost all the pressure on me. Like now I have to figure something out. I have to expand. Executive suites won't work because, in the state of Arizona, you need a sink and an aesthetician's room and executive suites don't have sinks. So, I started considering a larger plan. So, it really kind of grew from that point.
John: Okay. So, you're hitting on different things, mental health and then wellness and aesthetics. Has that grown from there to more services? You mentioned earlier like a therapist. So how does it kind of look now from the involvement of staff?
Dr. Brook Choulet: Initially it was really just me. Then I started talking to the facialist and then I started thinking, "Well, now we're focusing on mental and physical health and mind and body wellness and seeking inner peace and self-love and gratitude". So, I started thinking of what other services would be nice for that kind of space. Because right now, in Scottsdale at least, there are a lot of therapy clinics with a lot of therapists. And there are a lot of psychiatry clinics with psychiatrists, but there's no kind of wellness center with those two. And then separately, there are meds that fall on almost every block of Scottsdale. So, it grew into adding therapists, the facial aesthetician, a nutrition coach, and gathered this big team of people. And we're planning to move into a large space on north Scottsdale Road in November.
John: Okay. Is it the kind of thing where the patients will, and I guess clients if you're talking more of the med spa type thing, but they'll kind of self-select what they need and want? If you've got therapists, of course, there's going to be a lot of overlap with the psychiatry side of things. So, how do you anticipate that will work or has it worked?
Dr. Brook Choulet: Sure. I think a lot of times people have been calling saying, "I'm looking for a psychiatrist" and then you kind of triage them on the phone "Are you looking for medication management? Are you looking for therapy?" And then come to find out, maybe they meant therapy. So, I think the triaging part is really important because sometimes clients won't know what they're calling for. They'll just call because they want one of the services and then it's kind of our job to help match them to what they're looking for.
I think that's where that staff is really critical to the whole process because a lot of the private psychiatrists, at least here, will have all their new patient calls go to voicemail. And then they'll just answer them at the end of the day. But what I'm finding these days, as people want that kind of instant reward or instant kind of answer, so when they call, they really expect to talk to someone and that's something I wanted to provide.
John: Well, we all have our own experiences and our families and so forth where there's a need and when you need help, you need help. You want to get some kind of an answer or direction, even if the answer is "Well, we can't help you, but we can send you somewhere else". And it always amazed me why the psychiatrist didn't have closer relationships with therapists because invariably, oftentimes they're going to be making a referral, and pretty much they might give you a list or something and say, "Well, here pick one". It just doesn't make sense.
Dr. Brook Choulet: Right. I totally agree. It's much nicer for not only us because we know who the patient's seeing, we know kind of what their care looks like, but it's also nice that they can schedule their med check and then the next hour, they can see their therapist in the same office. One other reason I started considering some of those other services to add is that sometimes I have a lot of teens coming in and their parents are just usually waiting in the waiting room. So, if there's some other service they can be doing or preoccupying their time and making it a fun experience for them too, I think that's the ultimate bull.
John: How do you find time to organize and run this thing while you're in fellowship now? Or how did you do that when you were in your residency?
Dr. Brook Choulet: I now wake up very early. I go to bed very late. But pretty much outside of the hours where I was in residency year and fellowship, I'm constantly taking meetings on the phone, making sure admin stuff is running smoothly, making sure the people that are working at the clinic are happy because ultimately all I want is for this to be a happy positive environment where both the patients and the staff are really happy being there. That's my ultimate goal.
John: Now I'm going to digress for one minute because I forget sometimes that I have listeners who have never started a business. Maybe they went straight out of residency and they're working for somebody. And let me just run this by you. I mean, this is what I've done. If I want to start a business, I go to my accountant. I say I need an LLC or whatever structure you'd tell me. And I need a license to open a business in Illinois. And then I get an accountant to help me set up my books. That's basically it. Is that pretty much the same in Arizona?
Dr. Brook Choulet: It's pretty similar. Actually, what I tell all my friends too, who dabble in real estate or a side hustle or whatever it is, is make your own LLC. Don't pay someone else to do it. I think it took me a grand total of 25 minutes to fill out the form online. And you have an active LLC. Maybe in Arizona, they have a nice online system. I don't know what it is, but it was pretty simple. So, you do that, you talk to an accountant, you talk to an attorney and you open a bank account and you are kind of ready to roll.
John: Yeah. I think people think it's some kind of big mystery, but we have the benefit in most states in the United States that opening a business is easy. Now you still got to follow all the rules where it might get a little complicated later on. But if you have a good attorney and a good accountant, you can pretty much manage anything.
Dr. Brook Choulet: Right. And I tell people starting out too, if you go to executive suites and you rent an office there, you don't need a business license because the suite itself has the business license and you're just renting space out of there. So that is the lowest overhead way you could really get started with about $1,500 a month really, with all the things you need to kind of put in place between the suite, the accounting, all of these various aspects, and you could start out with pretty low overhead.
John: Okay. We're past that part. You've got this vision and you've started this. Now, you said you're in the process of moving into a bigger space now, where most everyone is going to be located, co-located.
Dr. Brook Choulet: Yes. We are moving into an office that's about 2,800 square feet and it has eight offices total. Everyone will be able to finally all be together rather than some of us are virtual right now, some have an office here. So, it'll be nice to be in the same space and for all of our clients to just come there.
John: What do you envision this will look like? Pick your number, two years from now, five years from now?
Dr. Brook Choulet: Yeah. I'm really hoping to have multiple locations in the next few years. I know I'm working with my mom right now who's a concierge psychiatrist on opening something similar there. So hopefully within the next year, we'll have something in San Diego as well.
John: Okay. Now we had talked a little bit before the interview. You brought up your mom as being a concierge psychiatrist, but from what I remember, her practice is different from what you're doing. And so, maybe you can compare and contrast the two and maybe the pros and cons if there are.
Dr. Brook Choulet: Sure. That's kind of where I got my idea of how to start everything really. She is in LA Jolla. Her name's Donna Kashani, she's an MD. She rented an executive suite and she does all of her own calls, billing, scheduling. It's really only her. She has someone that helps out with the billing at times. But other than that, she's the only one in communication with her patients.
John: And how long has she been doing that?
Dr. Brook Choulet: She has been doing that since we moved from Cleveland. So over 20 years.
John: Okay. I'm kind of working my way to asking you a leading question or one that will take some brainstorming. Maybe what other kinds of physicians do you think this would be doable for? We know concierge practices exist, but given that you're in the middle of it and kind of have lived it, do you think this translates to other specialties?
Dr. Brook Choulet: It definitely does. I did some coaching with someone in Florida who is an obesity medicine. My husband is also boarded in obesity as well as internal medicine. And obesity is something that could do really well. And I think it's a boutique practice. You just need an office. You need very minimal supplies and little overhead costs. So, I think that would be a good one. Integrative medicine, lifestyle medicine, functional medicine. And then really, I think some of the subspecialties could also probably do that, like endocrinology, rheumatology, maybe some of those too.
John: Okay. And I think what I was going to mention before when you were talking about the structure is basically, this is a cash-based business of which you've just mentioned others, the weight loss or the obesity and med spas and all that. So, would it be possible for an internist or a family physician who just wants to keep a small cadre of patients, would you say for them, would it be more of a membership model or the hourly type of model or either?
Dr. Brook Choulet: Right. I think that's why you do see so many internists and primary care docs with the retainer model because it's a little bit easier with internal medicine to know what you'll need throughout the year. You need an annual physical and you need certain kinds of sick visits, certain lab work. So, I think it's kind of a little bit more tangible to figure out what a package should include for internal medicine. With psychiatry, I have some patients I see every week, some patients I see every two weeks, some I see every month or every three months. So, to give a price on what that would actually look like would be really difficult. So, I think if a psychiatrist were to do a retainer model, they would have to have a kind of based number of services included and then an additional rate for any add-ons throughout the year.
John: All right. Well, before we get too far, I want to go ahead and put in the websites that the listeners might want to check out just to get an idea of what you're doing. And even if they're in the area, they could even look you up. So, you have your professional website brookchouletmd.com, which I think would probably have more directions to other things and links and so forth. But as far as the practice, it's at chouletwellness.com. Is that right?
Dr. Brook Choulet: Yes, that's correct.
John: It's very professionally done and very interesting. Well, stepping back, what do you think about physicians in general? Just sort of taking the bull by the horn and just trying to do something that isn't the standard cookie-cutter approach to medicine in general.
Dr. Brook Choulet: Yeah, I think it's amazing. I think at any point in anyone's career, whether you're in training, out of training, looking towards retirement, it's never too late. And I think it goes to show I'm kind of telling my mom like, "Hey, it's time to do something like this in San Diego". And she's used to her ways of doing things and it may seem really kind of scary or unknown to a lot of people, but once you start moving through it, you'll figure it out and put the pieces in place. So, I think it's amazing to kind of get out of corporate medicine and just make your own schedule and decide what you think would be a good work environment to go to every day.
John: It's hard to do because we sort of have this tunnel vision. We're focused on the traditional, what we thought was traditional, although once we get into the so-called traditional, it's never really what we thought it was going to be. So, we kind of break that mindset, I think.
Dr. Brook Choulet: Yes. And I see it because my husband is in corporate medicine in a large hospital system, and he's in the PSLF loan forgiveness program. So, he's kind of tied to that for a while, but there are pros and cons with the corporate jobs. There's security and income, you have a set schedule, but then the cons are that you're really not in charge of your own schedule. There's a certain way to do things. And some of the politics of the corporate medicine system may not be fun at times.
John: Well, that's absolutely correct, but I think a lot of people are fearful because of the financial aspects. Obviously, there's a risk involved, although if there's not massive overhead, the risks are minimal. But have you found in looking ahead, does it seem like from a financial standpoint and what the market will bear? Obviously, you've got to set your fees however you set them, and you have to find patients, you have to market. Maybe you could talk a little bit about that and then what's the response been once the patients see that you're out there.
Dr. Brook Choulet: Right. I think going to the first point, it's very important to think about finances when you're going into building something like this or something else because you really have to map out how much is this going to cost, what are the fees associated? And even though there's a lot of upfront costs, you don't want to kind of fall too far behind or put too much money and then not get that money out. So, I think it's really important to do that. And can you repeat the second part of that question?
John: Yeah. How did you get patients and clients? Is there a marketing plan? Was it kind of grassroots? How did that work out?
Dr. Brook Choulet: Yeah. So again, when you start a business, you want to run things as lean as possible from an expense standpoint. I just did it the old-fashioned way. I reached out to a bunch of therapists. I reached out to a bunch of the internal medicine docs I knew in town. I met with them for coffee, met for lunch, told them what I was doing. I ordered a bunch of postcards and sent them directly to physicians that were in private practice medicine or private OB-GYN and things that I thought my services would be helpful for. I really just tried to do it as kind of lean expense-wise as possible, and then also Google pay-per-click ads, and then having an SEO optimized website. Other than that, I didn't do anything really fancy.
John: All right. Well, I think there's a demand for that and there's getting to be more of a demand for a lot of these cash-based services because people are just tired. Well, they got huge deductibles to begin with anyway. So, sometimes you really feel as though you're uninsured. So, I think there's a growing demand. And then there's also the physicians who I think are going to be much more enthusiastic about running something that they control and not feel like they're being told how they're going to practice and when they're going to practice.
Dr. Brook Choulet: Right. I think that the most important point for the listeners to really consider is have you thought about days where you can decide when you go in and decide when your first patient starts and decide how you want to deliver care to the community, what you want to offer, what you don't want to offer? All the things that people get frustrated with when they work in a big outpatient setting or a big inpatient setting is a lot of those things are just out of your control.
John: Has there been much of a response from the medical students or residents or fellows around you that have seen what you're doing?
Dr. Brook Choulet: I try not to bring it up too much in training because it's just so different from what anyone else is doing or even has thought about. I mean, people are trying to get their medical license just to moonlight. So, I haven't talked too much about it and training, but I think maybe more people should, more people should know what the options are. I think it's definitely something that may be in my own fear of it not working out was holding me back from sharing it. But now that it's kind of up and running and things are going smoothly and we're getting a really good turnout of new patients for all of these people I've hired over the last two months then now I feel kind of more confident that this was a really good idea and I'm super glad I did it.
John: Do you feel like you're going to be involving other psychiatrists in the future?
Dr. Brook Choulet: Yes. I actually hired three psychiatrists in the last few months, so I have a few other MDs and a DO working in the clinic as well.
John: Okay. How was that from a contracting standpoint? Was that a challenge or is it pretty straightforward?
Dr. Brook Choulet: Pretty straight forward. Again, if you from the start have a business plan with your attorney and you knew what you wanted things to look like as you scale, then it becomes pretty straightforward. You go in knowing what you're offering, you know what's a good deal, you know it's really fair to the other physicians and it'll allow them to break free from the environment they are in.
John: That sounds good. They've started, right? So, they kind of know what they're getting involved with, and they've already been exposed.
Dr. Brook Choulet: I think that was a little interesting for a few of them. They're like, "Can I just ask how old you are and tell me about where you are in your training?" I think it was a little different for them definitely, to see that I was trying to scale this and grow this and that I really was confident and knew what I was doing. But they trusted, they jumped on board and it worked out really well for them.
John: Are these people that had been in practice for a short time, a long time, a combination?
Dr. Brook Choulet: Yeah, I think all three of them are in their forties.
John: Okay. So that must've been a little bit of a shift that none of them had tried their own concierge practice in the past.
Dr. Brook Choulet: A few of them are in other states. So, a few of them are providing remote services here and then another one is in person here and she has tried. The administrative part of things is very challenging. So, I think allowing that flexibility where you don't have to worry about scheduling and billing is really the best fit for some people.
John: Well, this has been fascinating. Any last bits of advice for any listeners today before we let you go?
Dr. Brook Choulet: Just go for it. That is my only advice. There's a lot to figure out and a lot to navigate. But if I can do it with kind of very little experience compared to some of the people who have been in practice for a long time, then I have no doubt anyone could do it at any stage of their career.
John: Yeah. That's very inspiring. You do have to be the type of person that wants to understand how to run a business. It is a business and you need to know those business principles. And that can be challenging, but it's certainly rewarding at the end of the day if you're not, basically, serving someone to someone else, some big corporation and you get to make the decisions and provide the best care that you can. All right, let me do those links again - brookchouletmd.com and chouletwellness.com. Check those out and see what Brook is up to. I guess that's all I have for today. It was very interesting.
Dr. Brook Choulet: Thanks so much for having me on today.
John: Oh, you're welcome. It's been a pleasure and I will have to check back with you in about a year and see how things are going.
Dr. Brook Choulet: Definitely.
John: All right. Bye-bye.
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Transcription PNC Podcast Episode 210
Want to Establish a Concierge Practice Before Finishing Your Fellowship?
Interview with Dr. Brook Choulet
John: When we as physicians become bored or frustrated with our practice or burnt out, our first instinct might be to leave clinical medicine. But we should stop to consider whether a different boss or maybe different partners or a different department in a big company or a different corporation or practice setting itself might be a really effective alternative. I know we talk about nonclinical careers here, but definitely non-traditional practice is another alternative. So, today we're speaking with a physician who has created a practice that avoids many of the traps of corporate medicine while she's still in training, if you can believe that. So, Dr. Brook Choulet, welcome to the podcast.
Dr. Brook Choulet: Thank you so much for having me here today.
John: Once I heard your story and I was talking with Brent Lacey, one of my podcasting friends, I thought this is really interesting because the things that you've implemented, I think are very instructive for many physicians who maybe feel trapped. And I thought, "Wow, this will be very good to share". Before we get into the specifics, why don't you tell us a little bit about your background and education?
Dr. Brook Choulet: Sure. I grew up in Cleveland, Ohio. And after many winters, my family moved to California. I finished high school in California, and then I ended up going to Kansas City, Missouri for the six-year bachelor MD program. My mom had actually done the same program and she really thought it was valuable and a good use of time. So, I was excited to head out there. I spent several winters again in Kansas City, and then I matched out in Phoenix for adult psychiatry residency at the University of Arizona College of Medicine, Phoenix. I did three years there, and then I transitioned to a child and adolescent psychiatry fellowship. And I'm currently in my last year of fellowship.
John: Awesome. That should be keeping you pretty busy but I think you have some other what we might call a side hustle or side gigs that you've been doing. Why don't you tell us what those are?
Dr. Brook Choulet: Sure, just to name a few. The first thing I did when the pandemic hit was I used some of that downtime when the clinic was in transition and residency to become a real estate agent. And that initially took me about a month and a half to complete that process and get my Arizona real estate license.
Then I started kind of thinking about what I wanted to do with the rest of my life after I was done with training and really decided I wanted to build a practice where things were on my terms and not the insurance company's terms. And I could actually spend time with my patients and spend valuable time hearing what was going on, hearing what their current life situation is. And that really led me to build this concierge psychiatry practice out here in Scottsdale. I started working on that in residency and it kind of took off from there.
John: Help define for us what concierge psychiatry would be?
Dr. Brook Choulet: Sure. There are a lot of different definitions of what concierge medicine is. I think to a lot of people, they might assume that it's a membership-based practice where you pay a retainer or you pay a certain monthly fee for access to the clinic. I think that psychiatry is such a unique field where you really have to connect with the person and the physician that you're going to. I wanted to avoid that model and I ended up just choosing a fee for service hourly rate model to really give not only the patients flexibility of where they wanted to get their treatment but also to make it more approachable for many patients who might struggle with the thought of a large retainer or membership-based fee.
John: Okay. That's awesome. And listeners, I want to make it clear. We are not going to go back and talk about real estate today. We're going to be talking about this aspect of concierge practice and maybe the general topic of just designing a practice that really meets your needs as a physician, rather than being sucked into corporate medicine, I guess, as some of us call it.
So, your concierge model is you have an hourly rate and you deal directly with patients. What about the payment? Is there any middleman in that payment model or not?
Dr. Brook Choulet: The clinic collects payments directly through credit card, we use Square and we use an EMR system where actually Square is integrated into the EMR system. So, there are actually no manual payments being run. You can set up a service, set up the price for it. And an hour after that visit it automatically charges for that service fee. And it really cuts out even anyone in the clinic having to run cards.
John: There's no billing per se or anything like that. Can patients take the information and then file a claim with their insurance company if they have one?
Dr. Brook Choulet: Yeah. There are a couple of companies out there. There are reimbursed five, better claims and they can assist kind of expediting that out of network claim, but that is up to the patient to do that part. The clinic is just responsible for providing that superbill.
John: That sounds like how it was maybe 30, 40 years ago when we would just have a paper, superbill and we would give it to the patient and say, "Well, this is what you owe us". And going through this, the rigmarole of trying to build these days, oftentimes even a small practice has hired like two or three people just to do that.
Dr. Brook Choulet: Yes, that is exactly why I looked at several different systems. And I really wanted to make things as efficient as possible, both on the clinic end and for the patients, because even nowadays I get invoices from outpatient clinics that are coming in paper mail, it has some access code. It wants you to go to a website, enter it, manually enter the payment. And for both the clinic and the patient, that seems really inefficient.
John: From what I know a practice like that is, like you said, it's more efficient and I use the word parsimonious, but you don't have to have a lot of staff to run it because you're spending the time with the patient generally and you have maybe a little bit of support. Tell us what that practice actually looks like in terms of staffing at this point.
Dr. Brook Choulet: We actually just went through a little bit of a hiccup, where the one staff we did have decided not to answer the phone and that's a pretty critical role in a clinic where we are providing such a high level of service. And so, we're currently in transition, but we have new staff starting on Monday. To answer your question, other than the physicians and the therapists that are talking directly to their patients, we just have one other staff member at all times.
John: There was a model in family medicine a while back, I forget what we called it, but it basically eliminated all the support. And there was actually a physician who was answering the phones, doing the billing, and running the EMR, but it was very limited and he spent basically 90% of his time seeing patients and didn't have to leave and have a receptionist, even though the office was open four or five days a week. There are ways of doing this in an efficient way that still serves patients very well. right.
I feel like there's still a lot of unknowns in how you put this together. How did this come about? You were in your residency, now you're in your fellowship. Maybe walk us through the steps, the "a-ha" moment, or what really inspired you to do this. And then what were some of the smaller steps in making this happen?
Dr. Brook Choulet: Sure. The smaller step is kind of what happened initially. That's building an LLC, getting a tax ID, opening a bank account. Kind of just some of those basic necessities of starting a business. Then you have to have your malpractice in place, consult some attorneys to figure out a business structure since there are so many different ways to structure a business. I think that's really critical. Without that step, you don't know where to go and don't know how to hire people. So, I think that was a big step.
And then really how this came about was almost random if you want to say. I had already started the practice myself, just seeing patients. I have an office and executive suites, very low overhead, just kind of doing my own thing. I was getting a facial and talking to the girl that was doing the facial about how unhappy she was in her current location. Just hearing some of the struggles she was going through. And I was talking to her about my desire or passion to build a large wellness center here.
We started talking and I kind of offered her a position on the spot. I'm like, I think it would be great if you join the center. I am not sure what I'm building yet, but I think you'd be a great addition. So, that's really the moment that put almost all the pressure on me. Like now I have to figure something out. I have to expand. Executive suites won't work because, in the state of Arizona, you need a sink and an aesthetician's room and executive suites don't have sinks. So, I started considering a larger plan. So, it really kind of grew from that point.
John: Okay. So, you're hitting on different things, mental health and then wellness and aesthetics. Has that grown from there to more services? You mentioned earlier like a therapist. So how does it kind of look now from the involvement of staff?
Dr. Brook Choulet: Initially it was really just me. Then I started talking to the facialist and then I started thinking, "Well, now we're focusing on mental and physical health and mind and body wellness and seeking inner peace and self-love and gratitude". So, I started thinking of what other services would be nice for that kind of space. Because right now, in Scottsdale at least, there are a lot of therapy clinics with a lot of therapists. And there are a lot of psychiatry clinics with psychiatrists, but there's no kind of wellness center with those two. And then separately, there are meds that fall on almost every block of Scottsdale. So, it grew into adding therapists, the facial aesthetician, a nutrition coach, and gathered this big team of people. And we're planning to move into a large space on north Scottsdale Road in November.
John: Okay. Is it the kind of thing where the patients will, and I guess clients if you're talking more of the med spa type thing, but they'll kind of self-select what they need and want? If you've got therapists, of course, there's going to be a lot of overlap with the psychiatry side of things. So, how do you anticipate that will work or has it worked?
Dr. Brook Choulet: Sure. I think a lot of times people have been calling saying, "I'm looking for a psychiatrist" and then you kind of triage them on the phone "Are you looking for medication management? Are you looking for therapy?" And then come to find out, maybe they meant therapy. So, I think the triaging part is really important because sometimes clients won't know what they're calling for. They'll just call because they want one of the services and then it's kind of our job to help match them to what they're looking for.
I think that's where that staff is really critical to the whole process because a lot of the private psychiatrists, at least here, will have all their new patient calls go to voicemail. And then they'll just answer them at the end of the day. But what I'm finding these days, as people want that kind of instant reward or instant kind of answer, so when they call, they really expect to talk to someone and that's something I wanted to provide.
John: Well, we all have our own experiences and our families and so forth where there's a need and when you need help, you need help. You want to get some kind of an answer or direction, even if the answer is "Well, we can't help you, but we can send you somewhere else". And it always amazed me why the psychiatrist didn't have closer relationships with therapists because invariably, oftentimes they're going to be making a referral, and pretty much they might give you a list or something and say, "Well, here pick one". It just doesn't make sense.
Dr. Brook Choulet: Right. I totally agree. It's much nicer for not only us because we know who the patient's seeing, we know kind of what their care looks like, but it's also nice that they can schedule their med check and then the next hour, they can see their therapist in the same office. One other reason I started considering some of those other services to add is that sometimes I have a lot of teens coming in and their parents are just usually waiting in the waiting room. So, if there's some other service they can be doing or preoccupying their time and making it a fun experience for them too, I think that's the ultimate bull.
John: How do you find time to organize and run this thing while you're in fellowship now? Or how did you do that when you were in your residency?
Dr. Brook Choulet: I now wake up very early. I go to bed very late. But pretty much outside of the hours where I was in residency year and fellowship, I'm constantly taking meetings on the phone, making sure admin stuff is running smoothly, making sure the people that are working at the clinic are happy because ultimately all I want is for this to be a happy positive environment where both the patients and the staff are really happy being there. That's my ultimate goal.
John: Now I'm going to digress for one minute because I forget sometimes that I have listeners who have never started a business. Maybe they went straight out of residency and they're working for somebody. And let me just run this by you. I mean, this is what I've done. If I want to start a business, I go to my accountant. I say I need an LLC or whatever structure you'd tell me. And I need a license to open a business in Illinois. And then I get an accountant to help me set up my books. That's basically it. Is that pretty much the same in Arizona?
Dr. Brook Choulet: It's pretty similar. Actually, what I tell all my friends too, who dabble in real estate or a side hustle or whatever it is, is make your own LLC. Don't pay someone else to do it. I think it took me a grand total of 25 minutes to fill out the form online. And you have an active LLC. Maybe in Arizona, they have a nice online system. I don't know what it is, but it was pretty simple. So, you do that, you talk to an accountant, you talk to an attorney and you open a bank account and you are kind of ready to roll.
John: Yeah. I think people think it's some kind of big mystery, but we have the benefit in most states in the United States that opening a business is easy. Now you still got to follow all the rules where it might get a little complicated later on. But if you have a good attorney and a good accountant, you can pretty much manage anything.
Dr. Brook Choulet: Right. And I tell people starting out too, if you go to executive suites and you rent an office there, you don't need a business license because the suite itself has the business license and you're just renting space out of there. So that is the lowest overhead way you could really get started with about $1,500 a month really, with all the things you need to kind of put in place between the suite, the accounting, all of these various aspects, and you could start out with pretty low overhead.
John: Okay. We're past that part. You've got this vision and you've started this. Now, you said you're in the process of moving into a bigger space now, where most everyone is going to be located, co-located.
Dr. Brook Choulet: Yes. We are moving into an office that's about 2,800 square feet and it has eight offices total. Everyone will be able to finally all be together rather than some of us are virtual right now, some have an office here. So, it'll be nice to be in the same space and for all of our clients to just come there.
John: What do you envision this will look like? Pick your number, two years from now, five years from now?
Dr. Brook Choulet: Yeah. I'm really hoping to have multiple locations in the next few years. I know I'm working with my mom right now who's a concierge psychiatrist on opening something similar there. So hopefully within the next year, we'll have something in San Diego as well.
John: Okay. Now we had talked a little bit before the interview. You brought up your mom as being a concierge psychiatrist, but from what I remember, her practice is different from what you're doing. And so, maybe you can compare and contrast the two and maybe the pros and cons if there are.
Dr. Brook Choulet: Sure. That's kind of where I got my idea of how to start everything really. She is in LA Jolla. Her name's Donna Kashani, she's an MD. She rented an executive suite and she does all of her own calls, billing, scheduling. It's really only her. She has someone that helps out with the billing at times. But other than that, she's the only one in communication with her patients.
John: And how long has she been doing that?
Dr. Brook Choulet: She has been doing that since we moved from Cleveland. So over 20 years.
John: Okay. I'm kind of working my way to asking you a leading question or one that will take some brainstorming. Maybe what other kinds of physicians do you think this would be doable for? We know concierge practices exist, but given that you're in the middle of it and kind of have lived it, do you think this translates to other specialties?
Dr. Brook Choulet: It definitely does. I did some coaching with someone in Florida who is an obesity medicine. My husband is also boarded in obesity as well as internal medicine. And obesity is something that could do really well. And I think it's a boutique practice. You just need an office. You need very minimal supplies and little overhead costs. So, I think that would be a good one. Integrative medicine, lifestyle medicine, functional medicine. And then really, I think some of the subspecialties could also probably do that, like endocrinology, rheumatology, maybe some of those too.
John: Okay. And I think what I was going to mention before when you were talking about the structure is basically, this is a cash-based business of which you've just mentioned others, the weight loss or the obesity and med spas and all that. So, would it be possible for an internist or a family physician who just wants to keep a small cadre of patients, would you say for them, would it be more of a membership model or the hourly type of model or either?
Dr. Brook Choulet: Right. I think that's why you do see so many internists and primary care docs with the retainer model because it's a little bit easier with internal medicine to know what you'll need throughout the year. You need an annual physical and you need certain kinds of sick visits, certain lab work. So, I think it's kind of a little bit more tangible to figure out what a package should include for internal medicine. With psychiatry, I have some patients I see every week, some patients I see every two weeks, some I see every month or every three months. So, to give a price on what that would actually look like would be really difficult. So, I think if a psychiatrist were to do a retainer model, they would have to have a kind of based number of services included and then an additional rate for any add-ons throughout the year.
John: All right. Well, before we get too far, I want to go ahead and put in the websites that the listeners might want to check out just to get an idea of what you're doing. And even if they're in the area, they could even look you up. So, you have your professional website brookchouletmd.com, which I think would probably have more directions to other things and links and so forth. But as far as the practice, it's at chouletwellness.com. Is that right?
Dr. Brook Choulet: Yes, that's correct.
John: It's very professionally done and very interesting. Well, stepping back, what do you think about physicians in general? Just sort of taking the bull by the horn and just trying to do something that isn't the standard cookie-cutter approach to medicine in general.
Dr. Brook Choulet: Yeah, I think it's amazing. I think at any point in anyone's career, whether you're in training, out of training, looking towards retirement, it's never too late. And I think it goes to show I'm kind of telling my mom like, "Hey, it's time to do something like this in San Diego". And she's used to her ways of doing things and it may seem really kind of scary or unknown to a lot of people, but once you start moving through it, you'll figure it out and put the pieces in place. So, I think it's amazing to kind of get out of corporate medicine and just make your own schedule and decide what you think would be a good work environment to go to every day.
John: It's hard to do because we sort of have this tunnel vision. We're focused on the traditional, what we thought was traditional, although once we get into the so-called traditional, it's never really what we thought it was going to be. So, we kind of break that mindset, I think.
Dr. Brook Choulet: Yes. And I see it because my husband is in corporate medicine in a large hospital system, and he's in the PSLF loan forgiveness program. So, he's kind of tied to that for a while, but there are pros and cons with the corporate jobs. There's security and income, you have a set schedule, but then the cons are that you're really not in charge of your own schedule. There's a certain way to do things. And some of the politics of the corporate medicine system may not be fun at times.
John: Well, that's absolutely correct, but I think a lot of people are fearful because of the financial aspects. Obviously, there's a risk involved, although if there's not massive overhead, the risks are minimal. But have you found in looking ahead, does it seem like from a financial standpoint and what the market will bear? Obviously, you've got to set your fees however you set them, and you have to find patients, you have to market. Maybe you could talk a little bit about that and then what's the response been once the patients see that you're out there.
Dr. Brook Choulet: Right. I think going to the first point, it's very important to think about finances when you're going into building something like this or something else because you really have to map out how much is this going to cost, what are the fees associated? And even though there's a lot of upfront costs, you don't want to kind of fall too far behind or put too much money and then not get that money out. So, I think it's really important to do that. And can you repeat the second part of that question?
John: Yeah. How did you get patients and clients? Is there a marketing plan? Was it kind of grassroots? How did that work out?
Dr. Brook Choulet: Yeah. So again, when you start a business, you want to run things as lean as possible from an expense standpoint. I just did it the old-fashioned way. I reached out to a bunch of therapists. I reached out to a bunch of the internal medicine docs I knew in town. I met with them for coffee, met for lunch, told them what I was doing. I ordered a bunch of postcards and sent them directly to physicians that were in private practice medicine or private OB-GYN and things that I thought my services would be helpful for. I really just tried to do it as kind of lean expense-wise as possible, and then also Google pay-per-click ads, and then having an SEO optimized website. Other than that, I didn't do anything really fancy.
John: All right. Well, I think there's a demand for that and there's getting to be more of a demand for a lot of these cash-based services because people are just tired. Well, they got huge deductibles to begin with anyway. So, sometimes you really feel as though you're uninsured. So, I think there's a growing demand. And then there's also the physicians who I think are going to be much more enthusiastic about running something that they control and not feel like they're being told how they're going to practice and when they're going to practice.
Dr. Brook Choulet: Right. I think that the most important point for the listeners to really consider is have you thought about days where you can decide when you go in and decide when your first patient starts and decide how you want to deliver care to the community, what you want to offer, what you don't want to offer? All the things that people get frustrated with when they work in a big outpatient setting or a big inpatient setting is a lot of those things are just out of your control.
John: Has there been much of a response from the medical students or residents or fellows around you that have seen what you're doing?
Dr. Brook Choulet: I try not to bring it up too much in training because it's just so different from what anyone else is doing or even has thought about. I mean, people are trying to get their medical license just to moonlight. So, I haven't talked too much about it and training, but I think maybe more people should, more people should know what the options are. I think it's definitely something that may be in my own fear of it not working out was holding me back from sharing it. But now that it's kind of up and running and things are going smoothly and we're getting a really good turnout of new patients for all of these people I've hired over the last two months then now I feel kind of more confident that this was a really good idea and I'm super glad I did it.
John: Do you feel like you're going to be involving other psychiatrists in the future?
Dr. Brook Choulet: Yes. I actually hired three psychiatrists in the last few months, so I have a few other MDs and a DO working in the clinic as well.
John: Okay. How was that from a contracting standpoint? Was that a challenge or is it pretty straightforward?
Dr. Brook Choulet: Pretty straight forward. Again, if you from the start have a business plan with your attorney and you knew what you wanted things to look like as you scale, then it becomes pretty straightforward. You go in knowing what you're offering, you know what's a good deal, you know it's really fair to the other physicians and it'll allow them to break free from the environment they are in.
John: That sounds good. They've started, right? So, they kind of know what they're getting involved with, and they've already been exposed.
Dr. Brook Choulet: I think that was a little interesting for a few of them. They're like, "Can I just ask how old you are and tell me about where you are in your training?" I think it was a little different for them definitely, to see that I was trying to scale this and grow this and that I really was confident and knew what I was doing. But they trusted, they jumped on board and it worked out really well for them.
John: Are these people that had been in practice for a short time, a long time, a combination?
Dr. Brook Choulet: Yeah, I think all three of them are in their forties.
John: Okay. So that must've been a little bit of a shift that none of them had tried their own concierge practice in the past.
Dr. Brook Choulet: A few of them are in other states. So, a few of them are providing remote services here and then another one is in person here and she has tried. The administrative part of things is very challenging. So, I think allowing that flexibility where you don't have to worry about scheduling and billing is really the best fit for some people.
John: Well, this has been fascinating. Any last bits of advice for any listeners today before we let you go?
Dr. Brook Choulet: Just go for it. That is my only advice. There's a lot to figure out and a lot to navigate. But if I can do it with kind of very little experience compared to some of the people who have been in practice for a long time, then I have no doubt anyone could do it at any stage of their career.
John: Yeah. That's very inspiring. You do have to be the type of person that wants to understand how to run a business. It is a business and you need to know those business principles. And that can be challenging, but it's certainly rewarding at the end of the day if you're not, basically, serving someone to someone else, some big corporation and you get to make the decisions and provide the best care that you can. All right, let me do those links again - brookchouletmd.com and chouletwellness.com. Check those out and see what Brook is up to. I guess that's all I have for today. It was very interesting.
Dr. Brook Choulet: Thanks so much for having me on today.
John: Oh, you're welcome. It's been a pleasure and I will have to check back with you in about a year and see how things are going.
Dr. Brook Choulet: Definitely.
John: All right. Bye-bye.
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