Episode Transcript
[00:00:00] Speaker A: What I really recommend for private practice owners is to know what your mission is. What is the goal? Why does your practice exist? And that's sort of the number one thing is, you know, for us, we really value having high quality patient care and giving our patients enough time. And so that wasn't really negotiable to us.
[00:00:19] Speaker B: Welcome to skin group. I'm Dr. Ana Chacon, and today we.
[00:00:22] Speaker A: Have a very special guest joining us.
[00:00:25] Speaker B: Get ready for some expert insights you won't want to miss.
Thanks for joining. Tell me a little bit about your journey, if you don't mind introducing yourself.
[00:00:36] Speaker A: Well, hi, yeah, I'm Carolyn Frankavilla. So I'm a family physician by training, but I always knew that I was really interested in preventive health and helping people prevent medical problems. So I wanted to do more lifestyle medicine. But I discovered the field of obesity medicine, which uses lifestyle as its foundation, but then layers on medications to help people lose weight. So I've been practicing in obesity medicine for more than a decade now.
And when I went into that field more than a decade ago, there was not like a lot of jobs for obesity medicine specialists. People had no idea what I was talking about. Obviously, in 2025, it's a different story. And so I did find a private practice that I started with, but I quickly realized I wanted to have my own practice. I wanted to do things on my own terms. And again, there really wasn't any other opportunities for me to practice obesity medicine and family medicine together at that point time. So with a partner. I started a practice almost 10 years ago. It's actually the practice is 10 years old this month, and we really wanted to focus on taking medicine back to basics, really getting to know our patients, having enough time to spend with them, and really practicing medicine on our own terms instead of sort of being told by outside forces the best way to treat patients.
[00:01:55] Speaker B: So you've been in private practice for about 10 years?
[00:01:58] Speaker A: Yeah.
[00:01:59] Speaker B: Did you work anywhere else before that?
[00:02:02] Speaker A: Yeah, I did work for a small private practice for a year out of residency, and I learned so much there. I learned a lot about the business of medicine, and it also allowed me to know that, that I did have the skills and was confident enough and had the resources to. To practice on my own. So it was a good jumping off point. But, yeah, a year out of residency and seven months pregnant, I started a practice. And then.
[00:02:25] Speaker B: Where are you located?
[00:02:27] Speaker A: I'm in a suburb of Denver, so I'm just outside of Denver, Colorado.
[00:02:31] Speaker B: Is your focus obesity? Do you do general medicine? And do you take insurance?
[00:02:38] Speaker A: Yeah, so we, we, I've always taken insurance, though. We have sort of added some membership options to sort of allow for the higher level of care that we provide. So we, we kind of are a hybrid at our clinic where we do a little bit of both, since insurance rates just aren't going up and we did not want to sacrifice the amount we spent with patients. So we do have a membership that allows us to do both. And so we, we kind of do a little bit of both. It's a hybrid practice at this point.
[00:03:04] Speaker B: And how about your focus on obesity? When did that start?
[00:03:08] Speaker A: Yeah, so I wanted to do that right from the beginning. And so I, from the beginning have done a mixture of family medicine and obesity medicine as obesity medicine has grown and I've sort of become an expert in the field and I'm on my national board of the Obesity Medicine association and I ended up, you know, creating a course on obesity medicine. I've definitely shifted a little bit more towards that in my practice, but I find it's hard to treat obesity without doing some of the primary care related to it. You know, we're still managing blood pressure and blood sugars and so many things that are related to weight. So even for my patients who they have another primary care physician, a lot of overlap exists there just with the nature of what we're doing when we treat obesity.
[00:03:54] Speaker B: What are some challenges?
Do you use a lot of GLP1s?
[00:03:59] Speaker A: Yeah. So obviously, like, you know, until a few years ago, we didn't have that as an option, so used a lot more intensive dietary strategies and older medications like Benjamin and Contrave and some of our other options. But certainly in the last, you know, couple of years, using GLP1s has really exploded and that has become sort of the main, the main thing that many patients want, though often, you know, having a physician who's like, familiar with other medications and other options is. Is really helpful because not everyone wants one of those medications or can't afford them or doesn't have access to them.
[00:04:37] Speaker B: And how do you feel now with the ban of some of the Titanic? I actually lost myself on the go to more.
[00:04:45] Speaker A: So I've actually never utilized compounds in my practice. Our Obesity Medicine association, again, which I'm on the board for, we've published a couple of documents, you know, about some of the concerns have with compounds, and the only reason they were really ever available was because of shortages. And so, you know, like any other med, I'm sure there's meds you use in your specialty that are expensive. They don't, they may not have a generic alternative yet. Right. And so that's the situation we are in for, for the GLP.1 medication, semaglutide and Tirzepatide is that there was, you know, a shortage. And so when there is a shortage, the government allows compounding pharmacies to, to make medications so people can continue having access but there's no longer shortages of, of branded, you know, wegovy or is that bound. And so you know, it's kind of like, like trademark infringement for people to continue to, to make compounded versions of those. But you know, I think we'll see prices go down actually this morning and I know that this, this may not air for, for many months but we're in February right now. They just announced this morning that Lilly has lower prices on their own vials that people can zepbound. So you know, we are definitely seeing the needle move forward on lower prices for the brand name drugs.
[00:06:05] Speaker B: What about future developments? There's, I'm trying.
[00:06:09] Speaker A: Is it.
Yeah, there's retatrutride which includes glucagon action as well. So that's one we'll see hopefully in the next year or so. There's Cargassemma which is another one that adds another sort of molecule to semaglutide and makes it more powerful.
I think we'll see higher doses of semaglutide recommended. There's some studies showing that. There was a study that came out recently showing higher doses of semaglutide and then there's many, many other drugs in development. So definitely over the next, you know, five to seven years we will have more and more options. Hopefully within the next year or two we'll have at least a couple more options. So it's just going to explode. And so another reason why I think seeing someone who, you know, an endocrinologist or an obesity specialist or someone who knows these medications, there's going to be multiple options and like picking the thing that makes the most sense for a patient is going to become more and more important over time.
[00:07:04] Speaker B: Bariatric surgery.
Do you work closely with them or do you try to do medical management?
[00:07:11] Speaker A: Yeah, so I worked in a, I did training in both med school and residency with a lot of bariatric surgeons. And so that helped me learn a lot, develop interest. And so I think as of right now that's still our most powerful tool. If people come to see me, they've often self selected that they don't want surgery. Right that's why they came to see a physician like me. But I'll always offer it if it's the option that I think makes the most sense and keep directing people back to it. You know, I have one patient right now who I've worked with for a while, really hasn't had success with any of the medications, has side effects to a lot of them, has a lot of weight that, that she would benefit from losing, and, you know, was really recommending surgery as the best option for her. If you want to lose more than 100 pounds, surgery is going to be the best option. So, you know, for people who have a large weight loss, I have another patient right now with type 2 diabetes. And same discussion. You know, type 2 diabetes is almost always reversed with bariatric surgery. So really, you know, trying to warm her up to the idea. But I find the patients who start with me usually spend five or six years working with me before they ultimately decide to get surgery. But again, that's like a self selection, right. People who really don't want surgery, and so they want to try everything else first. But, you know, in 2025, surgery is still our most powerful option. And so there's a lot of people for whom that, that may make the most sense.
[00:08:33] Speaker B: How just being in private practice, what challenges have you faced? I do take insurance as well.
Private practice. It's a very small amount of our patients.
It's just very hard to get on networks here. I'm not sure if you're in Colorado, but what is some of the challenges? How did you overcome them? Being on your own?
[00:08:57] Speaker A: Yeah, so. And I help coach people who are starting obesity practices. So these are things, you know, that we, we think about as a group too. And you never know what some of those challenges are going to be. You know, I navigated it and grew my practice through the COVID pandemic. I bought my partner out during that time period, became the sole owner. Like you don't know what challenges are going to come your way. And so what I really recommend for private practice owners is to know what your mission is, what is the goal, why does your practice exist? And that's sort of the number one thing is, you know, for us, we really value having high quality patient care and giving our patients enough time. And so that wasn't really negotiable to us. And so when we had different challenges come, come our way in the practice, my job was to navigate how do we still make that work. And so one thing is we've been really like lean with space.
So we have doctors who are in office someday and telehealth someday. All of us are part time. We have five exam rooms for what was four doctors and a nurse practitioner. We just expanded last week when we added another doctor. But we really tried to be as frugal as possible with things we didn't need so that we could spend as much time again as possible with patients. So knowing what your priorities are, your non negotiables, I think are really important. And then the other side of that is your practice has to make money, right? And so you have to sort of always be looking at the numbers. And if there's things that just financially don't make sense for your practice, you may not be able to offer them. So we all like to do women's health in our clinic. We like to do IUDs and Nexplanons. We think they're very important. But we, we're losing money when we did them for our Medicaid patients. And so we had to say we couldn't offer that service. Right. It doesn't make sense to be losing money on that, especially when we're in an urban area and there's other clinics people could go to. There was, you know, Planned Parenthood or other places people could get that service and we could help them navigate. And so if again, there's a service that you want to offer, but it doesn't make sense financially, you may not be able to offer that. So I think there's those two things. Knowing your mission, and then also you have to keep looking at the numbers, looking at reimbursements from insurance. And if there's something that doesn't make sense, if you have a insurance payer that just doesn't pay enough to make it doable, then you may not be able to take that insurance plan, for example. And then you may need to figure out ways to generate additional income for the practice. Is there other services that you can add on? You know, have you really maximized your billing and your coding? What makes sense to serve your patients? And so that's again, where we always come from at my practice, Green Mountain Partners for Health is what is our mission and how do we continue to be profitable without sacrificing that mission?
[00:11:45] Speaker B: I think that's awesome. And so are you the sole owner?
[00:11:48] Speaker A: I am the sole owner, yeah. So I'm the sole owner. And then we just had our fourth additional physician join us last week. So that's really exciting. And then we have one nurse practitioner who does obesity medicine. Only so there are six of us clinicians now and an entirely female team, which has been like a really empowering place to be, I think, for all of us.
[00:12:10] Speaker B: How do you meet people to work with? If you don't mind me asking, like.
[00:12:15] Speaker A: How do I find other doctors?
So honestly, Facebook has been where two of them. When we were first looking for the first doctor to add to the team, I just put on my own personal Facebook page that I was looking for another family physician and one of my sister's childhood friends was like, I think I know someone. And she ended up being like the perfect fit. She's worked with us for seven years now. She takes care of both my parents.
So Facebook was how we found her second doc. Also Facebook. I was in a like physician mom's group and saw someone in the west suburbs of Denver, was looking for a family medicine job. So I reached out, met with her. The fourth doctor was through like a mutual connection. She was a resident who had shadowed one of my friends. And the friend introduced us, the physician friend. And this, this doc was thinking about starting her own practice and I was like, that's great. You should totally do that. But if you want to feel like you're at a small practice in an independent practice and not do all the work, you could also consider just joining. And then she joined us and then the most recent doc actually reached out to me and said, your clinic is exactly what I've been looking for and basically wouldn't leave me alone until I offered her a job. So I think, you know, all in all, three out of four were sort of like social media people knowing that, that we existed, but really just networking at the end of the day is, is how I was able to build a clinician team.
[00:13:41] Speaker B: Awesome.
[00:13:43] Speaker A: So no job postings. Those never worked out, really. Just networking, letting people know. And then when people know it's a good practice and that doctors are treated respectfully, people want to work there.
[00:13:53] Speaker B: What future directions do you see? How big is your practice in terms of employees?
[00:13:59] Speaker A: Yeah, so we've utilized virtual assistants quite a bit. So we have three virtual assistants that support our practice and then we have two in person MAs and one office manager. So we actually only have like five staff members supporting what right now is five clinicians. Probably we'll add another virtual assistant soon. And I have, you know, a little bit of part time assistance that, that helped me with some tasks. But we again have kept things really lean and efficient in order to be able to serve our patients. Because if we had a giant team Then that's where all our money would be going. Right. So. So really efficient, lean practice. But yeah, we don't have that big of a staff. So.
[00:14:38] Speaker B: Yeah, you hear virtual assistants as well.
So you said you have one master.
[00:14:45] Speaker A: It's like a half of. Well, it depends. So I mean our virtual assistants are doing so many things that you know, in person mas would do. So yes, it's about a one to one ratio, which is pretty much what we've always maintained.
[00:14:56] Speaker B: How did you meet your amaze. Your current amaze. Where do you go about Facebook?
I knew I had some HR issues.
[00:15:05] Speaker A: Myself with my practice.
[00:15:08] Speaker B: You use like a consultant. Do you communicate a lot with you.
[00:15:12] Speaker A: Know, do try to initially what we did for our medical assistants is we. And this is different in different states. In some states you have to be licensed as a medical assistant. In Colorado you don't. And so we didn't have to have a formally trained MA and so I would hire pre med students who were in a gap year and I, I'm from Colorado, so my college was the University of Denver. So we would recruit from the University of Denver and it was really great. We'd get these really small, smart, bright pre med students who were really motivated and we would give them an opportunity that I never had which was to get experience in medicine. So there was a mentoring component to it as well. So that was really rewarding. You know, through the pandemic, staff hiring was a challenge. And as I kind of grew, we decided to go a more traditional route with medical assistance. And so now we've recruited medical assistants who are right out of MA school. And we just called sort of the local MA school which here there's like Concordia, I think those are all over the country.
And you know, we're able to recruit new MAs right out of school and so trained them and got their habits very good from the start. So, so that has been our approach now is more traditional mas, but I do miss our pre meds so maybe we'll bring them back in. But it did, it did get a little nutty with COVID and you know, if anyone was having hiring troubles in the last couple of years, like you know, if your practice, you know, it was newer in 2020 or beyond, you know, it's been really hard. It's been a big challenge. It wasn't always the case, but I think like looking for different staffing solutions. Right. Are there, you know, sometimes there's great part time employees. You might have, you know, a stay at home mom who wants to work 20 hours a week remotely or in office and might be a great fit. So if you're only looking for full time or you're only looking for people with certain degrees or certifications, you might be missing out on really great employees. So I think just being open minded, like someone who's an official medical assistant, may not be as good as a pre med who, you know, is really motivated and really knows the science.
[00:17:14] Speaker B: And then how did you come out on Medscape? How do you end up coming out on Medscape?
[00:17:19] Speaker A: I guess, like I don't even know, but so I'm the Chair of the AMA's Private Practice Physician section. So I do a lot to support private practice and try to advocate on behalf of it. And then I am also on my national specialty board for the Obesity Medicine Association.
I give lectures on both private practice and obesity medicine. So the more you just put yourself out there in different public ways, whether it's leadership positions or public speaking, the more different opportunities come your way. To the point where I can't even trace back where things are coming from at this point. You just sort of become like known for what you do. So I don't, I don't know even how I got interviewed for that particular Medscape article. It may have been through the AMA or the OMA and they have been through social media. Awesome. Excellent. Well, thank you so much, Dr. Francavela.
[00:18:09] Speaker B: I have to go and see patients, but thank you for joining me today and.
[00:18:13] Speaker A: All right.
