David Finkel is the Founder and CEO of Maui Mastermind®, one of the world’s premier business coaching companies with thousands of clients worldwide. He is a Wall Street Journal bestselling author of eleven books, including SCALE (co-authored with Priceline.com Co-founder Jeff Hoffman) and The Freedom Formula: How to Succeed in Business Without Sacrificing Your Family, Health, or Life. 

David’s syndicated business articles can be seen on Inc.com, Fastcompany.com, and Forbes.com and have garnered millions of readers and his work has been featured in several prestigious media outlets including the Wall Street Journal, Bloomberg, Fox Business, MSNBC, and Inc. Magazine. 

He has helped hundreds of thousands of business leaders grow their companies and get their lives back. He lives in Jackson Hole, Wyoming with his wife and three sons and is the son of a physician.


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Tobin Arthur, David Finkel

Tobin Arthur  00:04

Well, David –  good start, I want to start jumping into some tactics. And in this next set let’s talk about time, because much of this comes back to time management. And it’s not necessarily just brute force. And you talk in the book about the things such as hiring and making strategic decisions implementing core systems, there are ways to buy back time. But physicians need to bake a block of time, can you talk a little bit about what you recommend, in terms of those initial steps to start natural their time?

David Finkel  01:00

You know, Tobin, it’s interesting, in any professional service firm, the single biggest distinction people have about time is billable versus non billable. So in a medical model, what they’ll think is, am I doing procedure or consult time that I can bill for this unit of time, or for this grouping of work, and then they think that everything else is less valuable. And the irony is, is that’s not true. So we have a model based off of Pareto principle, the 80-20 rule, it says that 80% of what we do creates 20% of the result, it’s a very low value of time. And so for example, some of the admin might be a D level task, some of the things I have to deal with, just to keep things going. And then I might think about that 20%, that gives me 80% of the value of C time I think about that as procedure time. And I think about that as my consult time that I’m billing for. But I just did four consults. And in this past hour, I was able to bill for $115 per consult based on what I was doing. Great. What we have to realize, though, is that there’s more levels than that, if we take that 80-20 and apply it again, it says that 20% of the 20% gives me 80% of 80%. And all my physicians out there and dentists are probably saying, oh, that’s for every one hour, it’s 64% of my result. That’s pretty interesting, right? They do the math pretty darn quickly. And that might be for example, different for different payers. So for example, Blue Cross Blue Shield might reimburse this procedure at $2,000. Whereas I might have Aetna that, reimburse it only for $1500. So by shifting my schedule to take a little bit more Blue Cross Blue Shield is certainly in the prime periods, that’s going to go ahead and increase my revenue for the same unit of time by an extra two or $3000, $4000, $6,000 over the course of a week, multiply that by 50 weeks out of the year, that’s a big impact. And then if we do it one more time, one more math moment, if I take 20% of the 20% of the 20% will call that a time, that gives me 80% of the 80% of the 80% of the value, which means that that magic 1% gives me half the value. And it’s a pretty extraordinary thing. And so for example, I’ll just give one example from a medical client that I work with. Because he freed up a little bit of time to step back and think, he realized that he owned several different surgery centers. Plus he had some pain management practices, but he also had a hospital by taking his ambulatory surgery centers ASCs and turning him into hospital outpatient departments, he increased under his contract by close to 30 ish percent. The reimbursement for the same procedures by the same facility doing the same procedure under a better contract arrangement. The challenge is that most physicians will never have the time to think this strategically. Because what they do is they’re working 40 to 50 hours a week of clinical time, procedural time. And then any other time on the weekend or maybe one day a week they’re setting aside their spending doing admin and doing a little cursory look at their financials and even the financial side. They’re doing it poorly, because they don’t have the background.  I had one cosmetic surgery practice we work with. And I remember reviewing their financials they had broken it down by service lines, the cosmetic procedures they had a medical spa these other parts I said you realize that your medical spas are creating all kinds of headaches and hassles. Is that not true? And they said yes. I mean, it’s just it’s a hassle. We think we have to have it because people come into our high end cosmetic surgery practice. They love it. I said that’s interesting. Do you know that you’re you are paying a quarter of a million dollars per year to run your practice your spa. You’re making, you know, seven figures on the surgery, but you’re losing a quarter million dollars on the spa. They said What do you mean? I said look right here in your financials. Do you notice this number that’s in parentheses, that means it’s a negative number, they just never had taken the time to see that they didn’t have the fluency. So they just scanned and saw, okay, we made, you know, over a million dollars this year, we’re happy. Well, they weren’t not just making money, they were paying for the headaches for it, they closed that down, they made an extra quarter of a million dollars and their life was better. These are the things you can only do. If you have blocks of some time each week to think to step back and be strategic.

Tobin Arthur  05:28

That makes a lot of sense. I’m gonna talk a little bit about in a bit about teamwork, because that fluency that you were able to identify may not necessarily come naturally to them at first, but let’s talk about a concept you call the four DS delegate, delete, defer, design it out talk a little bit about, you know, as they approach their time, and they’re trying to figure out how to get some of this off their back there is a systematic way. And that’s what I get. That’s probably where you’re going with that formula. Is that right?

David Finkel  05:59

That’s right. So the first step for them is to ask themselves, how can I get rid of more mighty activities, because that’s where the most of them are. And that’s the lowest stakes the least value created. And so I look at who am I office? Can I hand off to delegate? What can I just not do just accept that it’s not going to get done? Delete? What can I just defer put off to later? Or even better? How can I design out like.  I’ll give an example. One of the family practices we had worked with – It was interesting to me, they had a large footprint physically. So in certain quarters there Wi Fi was low. And you say, Well, what does that matter? Well, when you add it up a time, they last about one console for three or four providers, nurse practitioner and or physician in this place every single day, every single day. Now, this is a group that had over 20 offices. So you can multiply that out. That’s extraordinarily a lot of money that all they had to do to fix that to Wi Fi extenders. That’s designing out the problem to give yourself back more time. It’s not, it’s not dealing with it. It’s saying how do we keep this from ever happening to begin with, and I’ll give one more concept or we call it a focus day. So most physician owners take a day or half a day to do “the admin,” the fact that they call “admin” just makes my stomach churn. Just instead, what I would say on your on your day that you’re going to do non clinical non procedural work, or your half day, give yourself a two hour block, just two hours, put it out there, when you’re at your best for most physicians, you know, it’s your, your 730, at nine o’clock in the morning till 11, right, that first block, and during that time, you’re not going to do admin, you’re going to do your A and B level stuff, which is the strategic work on the practice. And then the balance of the day, you can do your admin handing off more to your practice manager handing off more to your physician liaisons, handing off more to your front desk staff. But for two hours, you’re going to give yourself a chance to actually step back and do higher order things, which I’m sure we’ll talk about later what those things might be.

Tobin Arthur  08:01

Yeah, that’s great. And you don’t use the term but you’re using all the same concepts. You have some different nomenclature of OKRs objectives and key results or a quarterly plan. Can you talk a little bit about that idea of a quarterly plan? So now I’m taking some time, I’m thinking strategically, I’m not going to be in reactive mode all the time. What does that look like to have a quarterly plan?

David Finkel  08:23

Yeah, so the first step I’m going to do is I’m going to ask in my practice, what’s the single biggest limiting factor capital L capital F, the one constraint that’s my biggest constraint to growth for the practice and in in medical group, it’s almost always one of two things, it’s almost always going to be I need more patient volume, or I need more capacity. Generally, capacity is 80% of the time, that’s because I need more providers mid and or physicians. Or it might be that I’m needing to have certain type of front or back of office staff, for example, you know, there’s a an Orthopedic Group that is struggling right now. They don’t know how to find schedulers, that’s their big deal, they get a lot of referrals. But if they can’t get them scheduled, within 48 hours of the referral, that referral gets given to a different orthopedic practice, and it hurts that relationship. Well, they can’t schedule more because they don’t have the people. So I put my finger on what’s the single biggest point constraint to growth and once I have that now, I do a sweet spot analysis and simple technique we talk about and grow your medical practice, get your life back, but it works like this. I I brainstorm for 10 to 20 minutes, what are all the ideas I have to push back that limiting factor?  You know, if it’s patient volume, what all my different ideas to increase referrals to increase patient volume? Can I like for example, one of the GI practices we work with? They do obviously a lot of colonoscopies what when someone comes in and or someone that looks like the person driving them in is over, you know, 50 They remind them that hey, this is important for you to they call it their friends and families program that increase their volume by 20%. Just by implementing that simple system with that, and they’re helping their community I mean, they find they trust How many precancerous polyps that we found, these are people’s lives we’re saving with that. So I put my number one limiting factor on the spotlight, I brainstorm all these ideas, and I put them through two filters. One Pass through saying which are these are low hanging fruit, easy to do high likelihood of producing results. Second, separate paths, which of these are home runs, if it works, will have a big impact. And out of those 15 different ideas, you’re going to probably have one two or three that are both low hanging, and homeruns. Those are the ones I do first. And when I do that, now, my next step is I’m going to create an action plan. And an action plan starts as simple as one focus area later on, you’ll probably have two or three. And the good news is for the physician, he or she probably doesn’t own any of these steps, they just need to decide. And we’re going to hand off to their staff, we’ve learned with dental or medical groups that the owner physician should be involved to create strategy, but their team should be the one involved with execution and accountability. And that gets a much better result. And we narrow this down to a one page plan of action every quarter. So this rolling series of a 90 day sprint, what’s the Focus Area One, two, maybe three focus areas, what’s the detailed criteria of success, the the things that actually have to happen for the group to feel successful in this focus area this quarter in their practice. And then the main action steps and milestones with who does what by when. And that simple one page format, it’s in the book allows you to quickly and easily each week or every other week, check in with your practice manager, check in with your the person in charge of your physician referral systems or your marketing and check in with her and say, Hey, how are we doing, we said, By this point, these things would be done, I just want to hear from you how’s it going. And that simple shift takes maybe over the course of an entire quarter 10 to 15 hours of physician time over the quarter can radically revolutionize the business. That’s how a business person would approach a medical practice. And this is why it gives you a huge competitive advantage relative to the other physicians that are just practicing medicine, and not thinking business.

Tobin Arthur  12:13

There’s another half of that, that coin that’s very challenging for all business folks, including physicians. And that is, as you mentioned, you start to spend a little bit of strategic time, let’s say you’ve listed out you think, Alright, this is time to get my practice healthy. I’ve got 15 things I want to nail. And what you’re saying it goes back to your earlier principle, you’ve got to be willing to give yourself permission to say I’m going to defer 14 of those or 13 of those. And I’ve got a plan to figure out which one or two as you indicate. And I’m just going to punt on some of those things. And I have to be okay with that. Because the irony is, you may be thinking to yourself, you know what, this is the quarter, I’m really going to buckle down, I’m going to work some extra hours, we’re going to knock out six of these things. It just never really works that way does it?

David Finkel  12:58

It doesn’t. And and a physician should get this intuitively, I have a patient that comes to me and he smokes, he’s morbidly obese. And he’s got a massive bleeding problem going on right now, Which am I going to adjust, I’m not going to worry about the smoking, nor the weight, I’m going to deal with the bleeding or the fact that he’s not breathing. And so we triage we do that all the time in medicine. And in the business world, we know that less that we actually get done. And into work performing for you is much better than a lot that we start but never finish. And so we call it the fewer better principle, the idea that less is a lot more when the less matters more and actually gets done.

Tobin Arthur  13:40

I love it. And let’s wrap up this section with just that concept. And I’m wondering if you leverage this from Stephen Covey, I love I’ve always loved this is one of his key concepts. And that is a big rocks and little rocks. And I remember going 20 some odd years ago to a Covey workshop where they showed a you know, a glass that had was filled with sand and they asked you to stuff rocks into this glass. And of course, you can’t do that because the sand is immovable. And then the the cool experiment is you dump out the sand, you put the rocks in first and then pour the sand over and magically it all fits into the class. And that just stuck has stuck with me for decades that this idea of what are my big rocks, talk a little bit about the the big rock report and how this applies to everything you just talked about.

David Finkel  14:28

Yeah, I mean, most people and by the way did for sure come from Dr. Covey. His idea. I actually interviewed his co author Roger Merrill, 26 years ago at the very start of getting going doing this business stuff. And he was so gracious with his time his book, first things first, just just impacted me. Very cool. But the idea is this. We have this to do list and the to do list might go for pages and pages. There’s no way we’re going to get all that stuff done. We should never try to approach our time as if we can get it all done. What we should approach her Time is just say how do I pull my most important one or two things off of that list and put them visually separately that says this week, forgetting everything else that needs to get done these one or two things will create the most value for my practice. And if I do these things, which might only take me an hour, or two, or three, everything else is gravy that I do. We call those big rocks, these things that take less than two hours to do. And every week I look at all the things I could do, I look at my action plan of things I’m trying to get done. And I pick the one or two big rocks for the week. And then at the end of the week, I close the loop on how I did. Now we deal with coaching clients will also share their top victories, any challenges and other updates. And they have their key staff members doing this as an app based thing each week. And what it lets us do is it lets us have a one page printout for each of our key direct reports of what they consider most important and how they did what they were their victories we can encourage them about that. What were their challenges so we can help them with that. And then what did they choose as their big rocks for the next week? It’s just a simple discipline takes 510 minutes to do each week. But it qualitatively upgrades my use of time. Because now I know visually what can I do with my a time what my my two hour focus block. It’s one of those things maybe two. That’s it.