Episode 48: Building An HOPD Pain Practice From Scratch w. Dr. Nirmala Abraham

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This Episode

Interview w/ Dr. Nirmala Abraham

You Will Learn

– Dr. Abraham’s current opinion on the landscape of pain management practices as it relates to practice model, consolidation, ability of small practices to flourish, etc.
– Why Dr. Abraham insists on double checking her billing and coding for the procedures done.
– The reason Dr. Abraham says that “what brings you joy is the paradigm in which a physician should build their career and life.”

Resources & Links

I am excited to be joined by Dr. Nirmala Abraham to discuss the pros and cons of small pain practices. In this episode, she talks about her experience starting up and operating a pain practice as well as how a physician should go about building a financial model to understand the viability of a prospective plan.

Justin (00:00:04)
Hello and welcome to episode 48 of the anesthesia success podcast. This week I had a really awesome conversation with Dr. Nirmala Abraham. I love this discussion for a few different reasons. Dr. Abraham takes a real world approach to mentorship and clinical transition in pain management specifically, and she goes a really long way to tell pain fellows, Hey, here’s what you actually need to know to succeed as a physician. I found that she had this contagious enthusiasm and how she communicates. And I’ve talked to a number of physicians who point directly to Dr. Abraham’s influence as having a direct insignificant impact in their career contract negotiations or with their understanding of pain medicine.
Justin (00:01:02)
And so I’m really excited to talk to her today. Dr. Abraham did her anesthesiology residency here in Philly at university of Pennsylvania. She did a pain fellowship out in UCLA and ultimately she made a bold career move to come back across the country to Ohio to start an HOPD pain service from scratch. I really enjoyed hearing her tell the story and it was clear that we both really want to empower physicians with important information so that they can have really fulfilling careers that they cultivate on their own terms. And Dr. Abraham is really cognizant of trying to preserve physician autonomy and cultivated and allow it to grow and thrive and that’s something that I really appreciate about her. She literally started working in health care as a 14 year old, so she got exposure to contracts and billing almost 15 years before many of her peers, which is kind of hilarious and I know that you’ll enjoy her insights.
Justin (00:01:52)
Before I get to the interview though, real quick on some upcoming content, I’m going to take the next two episodes in episode 49 and 50 to share some of the things I’m seeing right now on pain management physician employment agreements. I’ve looked at about a dozen of them in the past month or so. And there were some really interesting and important concepts I want to spell out for anyone currently looking at contract. Things are influx with regards to coronavirus and I’ve seen some offers being rescinded and reshuffled. And so we want to talk about some important things there. We’re going to talk about RVU use. We’re going to talk about income benchmarking, asymmetrical risk for employer and employee in terms of compensation, as well as a few other topics that will either put you to sleep or put tens of thousands of dollars in your pocket. Definitely one of those two things. But I want to transition back to Dr. Abraham for this interview. We just dive right in and she shares about the beginnings of her career in healthcare.
Dr. Nirmala Abraham (00:02:43)
You know, as soon as you’re 14 and can get a work permit, you know, that’s, that’s how we roll in our family. It’s like, okay, you do what you gotta do to get a job, be productive even though you’re still in high school, but whatever. It’s just what you did. Yeah. And so it turns out, you know, family business for me was healthcare at that point. My father had been in hospital administration and a couple of local hospitals in the DC area cause I was, I was born and raised in Maryland. So that’s home. And so he had a healthcare management company that he had started up. And so that’s where I worked. And my first jobs were typing up and editing contracts for the DC government, for his home nursing company. Wow. So I did that and I worked in the home nursing agency.
Dr. Nirmala Abraham (00:03:33)
I helped do marketing and we would go to doctor’s offices cause this was, you know, this is old school, this is like, you know, 1987. So we’re literally having to get signatures on pieces of paper for the orders. So we were Dr.iving around to doctor’s offices, do that. And then he had a nursing school. So I worked in the nursing school, I did billing, I tr, you know, I typed out the forms for Medicare to submit for the home nursing billing. And so like, literally, that’s been my whole life. And then in college I got a job outside of the family business working in a doctor’s office. So I was doing blood Dr.aws, I was reading Holter monitors at the cardiologist side of the practice and checking in patients, checking outpatient, scheduling, doing authorizations. And so I did that in college and it’s like, Oh yeah.
Dr. Nirmala Abraham (00:04:23)
By the way, I did actually want to be a doctor since I was 12 so I’m not sure how this will ever be relevant. But okay now it’s time for med school and you know, get through that. And then all of a sudden, you know, and I, I did a public health major, I picked up a business minor and then go into med school and then all of a sudden I get out into practice and it’s like, Oh wow, that’s all really pretty helpful stuff to do. No kidding. So it sounds like your first experience in contracts and in billing started when you were 14 years old. That is correct. Well that would explain the deep expertise with which you’re communicating, right. Experience can’t be replaced and stuff like this cause you don’t find this in books. This is all live and learn it. Absolutely.
Dr. Nirmala Abraham (00:05:11)
And the business minor I’m sure helped as well. It did because it gave me some of the basics in terms of how to look at, you know, a spreadsheet and how do you look at a financial analysis of a program and it’s basics, you know, it’s not, you know, high end stuff, but just knowing, you know, this is accounts payable, this is accounts receivable, this is how the two work together and this is how you allocate your funds and this is how you process that. And even, you know, the, you know, HR one Oh one how do you staff, how do you communicate with different personality types and how do you keep people motivated and all of that. So you know, just these little things that I kind of picked up along the way have ended up making a pretty significant difference.
Justin (00:05:58)
Yeah. And that has been for you coupled with a real heart and desire to be, I think a mentor and a leader and help the, help the people coming up behind you, but the physicians who are trying to build their careers and trying to have this experience or at least benefit from this experience to be able to make great decisions. And that really comes through when you communicate. So talk a little bit about you know, the kind of what you’re seeing right now as far as I’ll say like resident and fellow preparedness. Cause one of the reasons that this podcast exists is because of this, what I call a significant informational asymmetry that exists between employers and prospective physician employees or potentially partners. So we’re trying to level the playing field. And I know you’ve tried to do that a lot with a lot of the work that you’ve done. What kinds of things have you seen and what kinds of mistakes have have physicians been making in this, in this context and you know, what are the things that we should be aware of?
Dr. Nirmala Abraham (00:06:57)
Well, I think what’s so tricky right now is the difference between what you are doing in your training and what you ultimately end up doing when you get out into the real world. I always catch myself say, Oh, you know, when I was in training it was so different. You know, like everybody does that. Every generation does that to the next group coming up. But I was one of the last ones that did not have the 80 hour work week. So there were no limits in how long they kept us there. You know, you lived it. And granted anesthesia was a little bit more forward thinking because we are literally life and death. And so they did recognize that, okay, if you’ve been up all day and all night working, you do need to go home and rest. You’re not going to be working for the next 67 hours and then get like four hours to sleep and then come right back.
Dr. Nirmala Abraham (00:07:54)
It was nuts. I mean it just, you know, but with anesthesia, that didn’t happen. And so we did have that. But in so many ways now, even when I’m watching internal medicine residents go through the hospital where I work, they do have a residency and I actually did my internship here. That is part of what ended up connecting me back to this community. But you don’t get that real world experience, right? Because you are working a 16 hour shift and then you have to be off for eight hours and then you come back. And so there is a disjointedness to training now where you didn’t have that before and so you had more time and you had that level of connection to people. That was a lot more consistent. So you had more time to get the information across and there’s so much to learn medically and clinically that where do you fit in?
Dr. Nirmala Abraham (00:08:50)
What needs to be learned to also thrive as a functioning practice? Right. And with anesthesia or anesthesia, it’s very different because it’s usually a very large group. You have a billing company, you don’t have an office per se, so you don’t have the overhead issues. You’re not dealing with that part of it. You know the HR stuff, you know that doesn’t really apply and so you’re able to have that in out. You’re just there, you do your thing and you go in pain practice. It ends up being very different because now not only are you not getting the contact hours, but you are going from a field where that wasn’t even relevant to the conversation to all of a sudden a one year fellowship of how to be in the clinic and run an office practice and an interventional practice and almost no time to figure that out because you’ll blink and your fellowship is done and then all of a sudden you’re joining your group, right, and then what? Or you try to start up your own deal and then what? Where could you possibly have found the time
Justin (00:09:53)
To learn that? Yeah. Either of those would be sort of polar opposites probably from a like a clinical model standpoint from the academic center doing a fellowship. Then you’ve got to move to either a smaller pain group or trying to understand how the business of pain medicine and how that works. It’s much more relevant in pain especially. And there’s very little, I was recently, I did a talk recently for a fellowship program who they got some of their pain fellows together and were talking about business dynamics of contracts and of different business models and just the implicate, like the very basic business one Oh one that you never get in fellowship. And so, you know, how, how does this idea apply to the pain fellows that you see and that you work with and how do you try to prepare them with these, a column like street smarts? Right.
Dr. Nirmala Abraham (00:10:42)
So I basically do it the way I was taught. And I was really, really fortunate to have an amazing mentor. Mike Bronte and I first started working with him during my residency at the university of Pennsylvania and he was the chair of the department there and I did my pain rotation and he was just running this phenomenal practice and it was in the black busy, basically like a private practice in academics, which is unheard of. That just doesn’t happen, that kind of efficiency and that kind of flow. The throughput, you know, it just, it wasn’t happening anywhere else. And so I was watching that happen and I thought, okay, this is, this is pretty awesome. And it made sense cause that’s how my brain works. I’m kind of programmed that way. My parents gave me the genetics for that business systems approach to everything and I am so grateful that they did not try to like program that out of me. Cause little sidebar, kind of funny story with that is my parents went to a parent teacher conference and you know, the teacher was like, you know, really love having normal in our class and you know, she’s so bright and you know, she’s just really a delight. But one thing that we’ve noticed is that she feels like she needs to be in charge of everything.
Dr. Nirmala Abraham (00:12:08)
And this was in kindergarten. And so thankfully my parents were like, well, you know, we feel that shows good leadership skills, you know, and they let it go. They did not try to, like, I have zero recollection of them ever saying, you know what, you should probably dial that back a little bit. You know, learn how to play nice with others and Dell really pause too much, you know, difficulty like they never did that. They were like, Hey, be your best all the time. And if that means you’re the one that gets to be in charge of stuff because nobody else can figure out how to do it, then go for it. And so, you know, at a very young age, that’s just how I was programmed to be. And so that’s how I saw the world. And so, you know, I’m looking at ways to be more efficient, to be more effective.
Dr. Nirmala Abraham (00:12:58)
And I saw Mike Ferrante doing that in the program and knowing that that was a direction that I wanted to go with my career, it just really made sense to me to be a part of that, which of course meant that during my CA three year he decides to pack up and move to UCLA. So I’m thinking, great. I used to just be able to hop on the train and two hours later I’m in DC and I’m home with my family. Now I got to move back across the country and do this because to me I felt like the only way that I was really going to get the training that I wanted for my future was to train with him. And so I moved and so I went to UCLA to do my fellowship. And basically within two or three months of getting there, I was the only one that knew how he wanted things done because I had watched it at Penn.
Dr. Nirmala Abraham (00:13:53)
And so we get there and there’s nothing in place, there’s no process for returning phone messages or for doing confirmation phone calls for appointments. And none of that was happening. And I, he started there in October of 2001 so it was just after nine 11 it happened. And so he left right after that. I went and interviewed, started that following July and I get there and he was like I need you to help me with this. There is nothing going right here. I need you to like see what the deal is. And so literally within like a month, I’m wanting the fellowship program with him as a fellow. So I’m sitting down with the staff and saying, okay, so this is how we take phone messages. This is, you know, and I noticed, you know, like a third of patients weren’t showing up. I said, okay, so who did the confirmation phone calls yesterday? And they’re like, I’m sorry, what?
Dr. Nirmala Abraham (00:14:54)
I’m like, Oh wow, okay, we’ve got to really get this figured out. And so within, you know, a couple of months, he was like, all right, you want the job? Like I’m going to need somebody else here to help me out with this. Because of course for him, you know, he’s big time research, all that stuff. Not that he couldn’t be operational, but he needed someone to be operational. And so he just started handing it all over to me. And so what he would do is, okay, here’s what we’re doing, here’s the patient we’ve done the visit. Okay, fill out the scheduling slip, fill out the billing, and just hand it to me when you’re done. Okay. And so that’s what he did. So we learned it. So you did it yourself from the beginning. So it’s okay, here’s our scheduling slip. These are the most common at the time, ICD nine codes here are the most common CPT codes.
Dr. Nirmala Abraham (00:15:50)
And so you’re just going to circle this and you’re going to do this and then you’re going to turn that in. And then once you’ve done the work, this is the charge slip or the office visit. And so these are, you know, this is what you do. And so that’s what he did. So that’s how I learned it. And so then it just made sense moving forward to say, okay, what better way to learn than right then when it’s happening because then you get to connect it to something. And so I remember pretty early on, it was probably maybe the third or fourth class that I was teaching of fellows that had come through. We went to an asthma meeting and I ran into one of the old attendings from Penn and I were talking and you know, we were discussing how we’re having some difficulty getting certain procedures authorized and stuff.
Dr. Nirmala Abraham (00:16:41)
And so we’re just talking back and forth. And then the fellows afterwards, they kind of looked at me like did you notice that you’re you mostly talking in numbers? And I was like, what are you talking about? They’re like everything. It was all like diagnosis codes and CPD. Like you guys were just going back and forth in code. You weren’t really using very many words for that conversation because at that point, you know, this was all still very paper based, electronic medical records hadn’t really taken over. So you just memorized everything. And so to them that was just fascinating. I was like, okay, well, you know, numbers stick in my head. It’s not a big deal. I still remember birthdays of people that I went to third grade with and so to me it’s like that was just how you were going to learn.
Dr. Nirmala Abraham (00:17:29)
So that’s how I taught it. I made sure that as each visit was done, I would talk through, okay, this is why we use this code. This is why we are going to phrase the documentation this way. This is how this translates into them being able to get the right authorization. Because if you don’t have the right codes and you don’t have the documentation to match it, then you’re not going to get this approved and that’s going to delay you being able to take care of the patients. So it was just an every case by case and Oh yeah, by the way, if you do it this way, it’s going to get denied because this information isn’t available. Or if you use it, use this code for this procedure, it’ll get denied. Because the last thing we heard from the billing company is that they’re not covering it for that diagnosis code anymore. So it was an on the fly case-by-case and then you know, within a couple, three months it’s like, alright, now you’re going to do it and I’m not going to say a word. And then if I have questions about it, I will ask you and kind of grill you on it. So that’s, that was basically what happens to me, how I learned it, and it just made sense to teach it that way as well.
Justin (00:18:38)
Sounds like absolutely invaluable experience and like an ear replicable learning environment where you came in as a resident who understood the operations and you know, during your fellowship here you’re probably picking up the clinical skills of doing interventional pain, but you’re also sort of teaching people how to run the clinic at the same time. So talk about you know, there was a transition away from UCLA and you’re in Ohio now, is that right? Okay. Okay. Yeah. So talk about what it was like to leave the nest and take and take all of these skills that you had so diligently built up over years and, and, and sort of do it from the ground up.
Dr. Nirmala Abraham (00:19:22)
Like I had mentioned earlier, this is the hospital system where I had done my internship before my anesthesia residency. And so basically it was one of those situations where when it becomes clear that God has a different path for your life, it’s usually a good idea to listen and not try to do the opposite of where he’s trying to send you. And realistically, I had always seen myself in a private sector, but I, because of where I was and the opportunity that I had, I stayed on at UCLA because like I said, Mike offered me the position pretty early on in the fellowship ear and I started to realize how much I enjoyed that environment. I enjoyed the challenge, I enjoyed the complex cases, I enjoyed the back and forth of being challenged by the people that were trying to learn from me because then I could learn from them as well.
Dr. Nirmala Abraham (00:20:19)
And we were in an environment where that was being supported and yes, it was important to be efficient and effective and code correctly and maximize our revenue stream and you know, all of that was happening. And so I didn’t feel like I was missing out on that in any way. And then I had the bonus of having people that I could have these conversations with and have this ongoing dialogue of what is the best practice, what can we do that is now cutting edge and different and all of that. So I had originally thought I’m going to go do fellowship. And then leave, you know, get a ton of world experience and then come back and teach. And so I’ve kind of done it backwards. I stayed, I taught, gave some experience and then went out into the big bad world. And I may end up in academics again.
Dr. Nirmala Abraham (00:21:03)
I may just find other ways to teach. I don’t know because I still love doing it. How long were you at UCLA before you departed? I was there from 2002 to three as a fellow and then from three to 10 as an attending. Got it. Okay. So yeah, eight and a half total. Okay. And then went from there to Ohio, is that right? Yes. So basically the operative opportunity came up that they did not have a pain management program affiliated with this health network. And at the time they were doing more total joints than Cleveland clinic and they did not have a regional anesthesia program. They did not have an acute pain service. They had nothing that they needed on the inpatient side. And in order to, you know, build up all of the certifications for center of excellence and all that kind of stuff, you needed to be able to document that you had certain things in place and they had a very skeletonized and not really a cohesive program in place.
Dr. Nirmala Abraham (00:22:05)
And I really had just come here for a social visit and went to hang out with some of my attendings in, in med ed and went to say hi. And everyone’s like, Oh wow, we would love to have someone like you here. I’m like, yeah, I could walk to the beach from my condo, so I probably don’t need to be back in Dayton, Ohio. Except like I said, when God starts to open doors and every conversation that I had when I got back to the California from this trip was somehow with someone that had lived in or was from Ohio. Like, okay, I get it. I’m apparently supposed to be going back to Ohio. And as it also turned out, my practice manager at UCLA was born and raised in North Dayton. Oh wow. And so she too had been wanting to come home. I’m like, great, so you wanting to go home is taking me to Ohio instead of to my home in DC.
Dr. Nirmala Abraham (00:23:04)
So basically what we did as it became clear that this was a direction that our lives were going to be heading was we Dr.afted a business plan. And so she had actually done her MBA while working for our practice and I had helped her with the project. She basically used our office for all of her projects because it was a healthcare administration focus for her MBA. And so she would keep picking random things that we needed to improve upon. And then, because you know, back then the wifi connection was not very good at her apartment, so she would stay at the office late to her homework. And so I would hang around sometimes and help her out with the projects and stuff. And so then when the opportunity came up here, it was basically to start a department from scratch. Nothing existed, which was so energizing because all of a sudden the, we could do exactly what we wanted to do.
Dr. Nirmala Abraham (00:24:08)
So everything that we did like about what was happening at UCLA, we’re like, okay, if we are theoretically being given a blank check here, we’ve got to run with it. So we, and we went all out, we had a program to help us write a formal business plan. So we started off with our executive summary. We did research to find out what the mission statement was for this institution. And we basically built the entire business plan around that and set up three months, six months, one year, three year, five year and 10 year projections for what we wanted to do and what we thought we could accomplish. Because at that point we were pretty close to 10 years at UCLA. So we felt like, okay, so we can watch the growth of what we’ve done here and pretty much replicate that at a new location.
Dr. Nirmala Abraham (00:25:03)
So when you’re talking about those projections, is that in terms of like, I guess patient volume and like revenue to the hospital and different types of procedures and reimbursed and all of that into account? Yes, absolutely. So we start off with, okay. I recognize that what you want is, you know, coverage for orthopedic surgery. And so the recruitment happened because the last person I met that visit happened to be the director of the orthopedic service line for the hospital. And so she was like, and my friend that I was visiting, she was a trip, she was introducing me to everybody with my credentials. She’s like, Oh, do you remember this is Dr. Nirmala Abraham. She did her internship here and she is now the assistant director of pain management at UCLA. And this person heard that intro and she was like, wait, what? We need to talk right now.
Dr. Nirmala Abraham (00:25:56)
And so she’s pretty much, that’s what she did. And so she’s like, okay, so this is what we’re trying to accomplish and this is what’s happening. And you know, I’ve been trying for about five years now to get this going and I’m just really having a difficult time. And I just looked at her, I said yeah, what you’re doing is never going to work. And she says, Oh, okay, why? So I said, well, if you’re trying to contract private doctors to come in and provide inpatient services, that is an automatic loss of revenue for them because every minute they spend in the hospital is time away from revenue generation in their procedure suite or in their own clinics. So you’re never going to get anybody to really commit to this. So what you need is a physician that works here that is going to have a thriving outpatient pain practice that is interventionally based so they can generate the revenue stream, which will then support the loss that will happen on the inpatient side because it is going to be a loss on the books.
Dr. Nirmala Abraham (00:26:55)
But obviously improved quality of care, improve patient satisfaction, decreasing length of stay. All of those other things will ultimately gain you back and will net you a positive. And she looks at me and she said, okay, so you explained to me in one minute what no one has been able to tell me for the last five years. How does that happen? I said, it happens because this is my life, this is what I live, this is what I do. And as the assistant director of a fellowship program, I am required to balance an inpatient experience with an outpatient program. And the way we do it, we make it run really well and we do it very efficiently and very effectively, both clinically and financially. And so this is just, this is all I know. And so she’s like, all right, that’s what we need here.
Dr. Nirmala Abraham (00:27:51)
So that’s basically what I did for them is create that model is here’s your outpatient practice. This is where the money is going to come from. It generates X amount of dollars on the hospital side with the procedural fees and facility fees that come in. It generates this much on the physician side with the professional fees. And then this is a rough estimation of expected volumes and throughput. This is what we can do on any given day. And and so this is the split. So is there always this CSR relationship between the outpatient pain and the, you know, the inpatient stuff where it’s essentially one is subsidizing the other? Is that kinda the way it works in pretty much, yeah. Cause ultimately the amount of time spent in seeing the patients dealing with the inpatient side of it, the rounding and all of that, you’re just not going to recoup that time and the amount of money that it would cost you.
Dr. Nirmala Abraham (00:28:56)
And the other thing is that you cannot have physicians running that side of it, right? You have to have the advanced practice providers on that side of it because there’s no way that you’ll be able to come close to generating enough revenue to cover a physician salary on that. But you do come pretty close to a PA or nurse practitioner salary. And especially if you’re looking at what you end up gaining by reducing your length of stay and improving your quality metrics and all of that. So there is always going to be that balance. So whether it’s built into the surgery side and the surgery department in the hospital takes on that responsibility or if there is a pain program that is set up, there is always going to be that back and forth and that balance that has to be found.
Justin (00:29:48)
Okay. So it sounds like the HOPD side is the side that kind of got you excited when you’re like, okay, clean slate, blank check, let’s roll up our sleeves. So tell me about this transition coming back. You’re probably looking for a place to live and then your show up at the hospital and you’re like, let’s do this. What was that like?
Dr. Nirmala Abraham (00:30:07)
So I showed up for my first interview cause they, you know, they’re like, okay, we want to meet with you and, and see what we think. So I show up and you know, one of the people from the physician employment side was talking to me about, Oh yeah, you know, you know, pain management is, it’s, you know, it’s kinda tough here in this community and we don’t really have anybody here. And I said, yeah, well, you know, there’s a lot of opportunities and you know, obviously there it’s tricky to balance this and you know, get the right revenue stream going and all of that. And he just kind of looked at me and I said, well, if this doesn’t make sense, I can, you know, here’s a copy of my business plan, if that would help it be more understandable. He’s like, I don’t think I’ve ever met a doctor that actually knows what any of those words mean.
Dr. Nirmala Abraham (00:30:51)
And he’s like, I’ve definitely never met a doctor that showed up to their interview with a business plan. And I said, well, it’s all I know. Again, it’s a brand new department and to me there’s no better way to explain it than to show you what it looks like on paper. And find that balance of the clinical information to help you understand what we do clinically combined with what does this provide as an added service and added value to the system. So basically I did six or seven interviews in one day and every single one of them ended with, okay, what’s it gonna take to get you here and how fast can you move? And so that was in April of 2010 and I moved out here in December. So yes, let’s move back East in the winter time. That was, yeah, it was rough. So basically I went through like three or four of the top life stressors within like six months because I had to change jobs. I left the only job I ever knew. I left my mentor, I had to sell my condo in LA. I bought a house out here. I moved, I went to 1314 houses in one day and take one signed on it.
Dr. Nirmala Abraham (00:32:13)
You know, and that’s kind of my sort of how I function. It’s like, look, we just need to get this done. So let’s look at this. Let’s, what do we want? What are the, what are the absolute must haves? What are the, I don’t care about this so much. What are the absolute, Oh no way. This is not an option. And get that going. And there were some houses that I walked in and like 30 seconds like, Nope, we can go onto the next, you know, and that’s kind of how function my, the, the service line director who ended up managing us for the first few years that I was here, she kind of laughed because when we met with the architects, it was a blank slate. Like literally the walls weren’t even built yet in the clinic in that the section that they were allocating for us.
Dr. Nirmala Abraham (00:32:56)
So we sat down with the architects and they had a design and I’m like, yeah, you can’t put the doctor’s office right next to the front desk. That’s a really bad idea. So let’s redesign this and we’re going to do this. And then the, you know, the interior design person was like, okay, here’s some ideas I had. I’m like, okay, that one, that one, not that one. We’re going to do that. Okay, we’re done. And she just looked at me, she like, I have never had anybody figure all of this out that quickly. I said, yeah, now I know what I want. I know what I want. I’m not afraid to ask for it. I’m not afraid to say no, this is not what I want. So, and there’s other more important things to worry about, so let’s just keep moving along and get things going.
Dr. Nirmala Abraham (00:33:38)
So it was, you know, it moved along pretty quickly. Was the architect with whom you were working, did they have any experience in op like building a, a floor plan to be optimized for, you know, patient flow in a hospital outpatient department? They thought it was like a specialized skillset. Yes. They thought they did, but turns out they didn’t. And so again, having spent a lot of time thinking about, okay, what is the ideal flow? Like we had moved to a couple of different offices when we were at UCLA and they were in the process of trying to design another space for us to move into. So the manager that actually ended up coming with me from UCLA to here, we’ve now been working together for 17 years. Wow. Which is unbelievable. Yeah. Yeah. And so she and I had, you know we had, that’s what we did cause I was running the operational functional side of the practice at UCLA.
Dr. Nirmala Abraham (00:34:33)
She was the manager. So we were, you know, hand in hand the whole time redesigning space, looking at what the flow was. Okay this is horrible. We need to fix this and do this differently. So again, when we had the opportunity to design from ground zero, we said okay, we like sort of what you’ve done but here’s the areas where this doesn’t work. And so we sat down with them and kind of redesigned it and explained it, said okay if you want the patients to come in here and then the flow needs to go to, you know the MAs to get them checked in to do this and then you need to take them to the rooms. And then you know, you need the clinical space for the physicians. You know, you need office space, admin space and you want to separate that from patient care areas because you want them to have privacy. You want them to be able to get away from where the patients are to do what they need to do. So the architects had never really even thought about it that way. And so when I was talking to them, they were like, Oh wow, that really does make a lot of sense. Yes, yes it does. Did you just pick all this up intuitively from your time at UCLA? Is this something that
Justin (00:35:38)
Most people who having worked in a paint department would be able to Intuit?
Dr. Nirmala Abraham (00:35:43)
Probably not. I mean, I think a lot of people can get bits and pieces of it, but one of the things that I’ve always been able to do is look at the, you know, the 20,000 foot view from above and just kind of see all of the parts moving and say, okay, this, this is what would be the ideal. So you know, for as much as I am a very detail oriented person and want X, Y and Z to be in line, I can also see where if this isn’t happening, that’s how is going to impact all of these other things. And so there are some parts of it that you would just be able to figure out like yeah, you definitely don’t want the break room to be right next to the patients. You don’t, you know, there’s certain things that you would just figure out were poorly thought out, but then there’s other little details that you may not think of in terms of layout and you know, where, where is the most efficient location for the medical assistant?
Dr. Nirmala Abraham (00:36:51)
Where do you want the scheduler to be? How do you want check in and check out the flow in the front desk space. And you know, there’s a lot of that that physicians don’t necessarily think about because to them they’re handed a chart, they walk into an exam room and that’s it. All they think about, they don’t think about all of the steps that it takes from when the patient walks through the door and then they have to be guided through this visit. Not everybody’s going to even bother to think about it that way because most physicians that’s not relevant to them.
Justin (00:37:22)
Yeah. Were there any other resources that you had to Dr.aw from in order to answer some of these questions?
Dr. Nirmala Abraham (00:37:28)
Not really. It was just kind of a, like I said, live and learn it. Yeah.
Justin (00:37:33)
And just watch it happen. Yeah. After the layout was kind of configured, talk a little bit about, you know, getting outfitted and then how long was it until you had patients coming in the door?
Dr. Nirmala Abraham (00:37:42)
So I started in mid January and the first patients were by the end of February. Okay. So when he got here the clinic was not quite finished. We did not have phone lines. They did not have any phone number yet. So that means we didn’t have business cards. So I couldn’t do the marketing that I had initially hoped to do. But I did start getting out and meeting some of the doctors at the hospital level. Met with some of the orthopedic surgeons that were there and talked about the fact that yes, we’re starting up the outpatient program and we’ll eventually be providing inpatient services. But it’s just me right now. I did have a nurse practitioner that was hired part time, but you know, this was going to be a huge undertaking cause it was just me as a physician and in a specialty that the hospital didn’t have.
Dr. Nirmala Abraham (00:38:32)
And what I did not know at the time was that Dayton was in the midst of their opioid crisis peaking. And I had no idea it was that bad. Yeah. And within months of getting here, how spill 93 passed, which is the one that cracked down on the pain clinics and what was the definition for a pain clinic. And so all of a sudden you had a bunch of practices that were trying to get rid of all of the patients that they’ve been prescribing opioids to for years. Right. And then on the inpatient side, they saw so much in the way of complications from Dr.ug use, IB Dr.ug use overdoses and all of that. And so all of a sudden the inpatient side became a lot more complex and the outpatient referrals were also a lot of people just trying to dump off on the newest pain practice in town.
Dr. Nirmala Abraham (00:39:24)
Let’s get rid of these patients. So I got out, I started meeting with people told them the outpatient practice was starting up and hopefully in three to six months we’d get some inpatient stuff going. Yeah. Except that the first patient I saw was an inpatient because one of the first surgeons that I met with had a patient that was on methadone and was getting a knee replacement and he had no idea what to do for postop pain control for a patient that’s been on methadone. And so, you know, everything got flipped completely upside down and I ended up starting both inpatient and outpatient at the same time. So that was challenging.
Justin (00:40:03)
Yeah, no kidding. What strategies did you find to be most constructive as you’re trying to get the name out there? That, you know, we have an outpatient pain clinic now we want, we’re trying to get patient volume up so we can like pay for this big shiny new facility that we just, how did you go about doing that?
Dr. Nirmala Abraham (00:40:20)
So basically I just had to tell them a little bit about what I was going to be doing and how it was going to be different from the other practices in the community. At the time that I got here, I believe there were 22 or 23 providers that were calling themselves pain management and only six of them with me included were actually fellowship trained and board certified. Wow. Everybody else was some variation of primary care anesthesia, some thing and had sort of grandfathered into doing pain management because you know, they went to a few weekend courses and stayed at a holiday Inn express and all of a sudden they got to call themselves pain doctors. And that’s kind of the terrifying thing about the specialty is it is still very fluid in terms of who is allowed to call themselves pain management and the certification that’s required.
Dr. Nirmala Abraham (00:41:15)
Now, Ohio has tried to tighten up on that, but that doesn’t change the fact that there are still several practices that are grandfathered in. And so we still kind of struggle with that. But you know, I did let them know. Yes, I do moderate prescribing, but not a lot. This is going to be an interventional focus. My philosophy is functional restoration and that means we are looking to do things that will actually help the patients be better and be stronger and be more interactive in their lives. And so that happens in a variety of ways. Mostly with us doing interventions and things that are going to more directly go after the pathways that are creating the pain meds when appropriate. Treatment oriented, not so much on the opioid side. And you know, just let them know kind of the range of what I could do and let them know who is the them.
Dr. Nirmala Abraham (00:42:13)
So the them was mostly surgeons. I started off meeting with the orthopedic surgeons find sir in the hospital. Yes. Okay. So in the hospital I’m affiliated with the system. And then I did some lectures, I did some grand rounds and some different things to sort of let people know what I had to offer. And then on the inpatient consult side, same thing, you know, it’s mostly gonna be acute on chronic pain. Some, you know, mostly postop, honestly at the beginning. But like I said, the minute they had somebody that they knew was in the hospital, all of a sudden it was like the flood Gates. Like, Oh you know, this person is addicted to heroin and now they’re having a surgery. So you need to take care of that. Okay. Not licensed in addiction medicine. Not going to be managing the addiction can help you as much as I can, but there’s not a whole lot to offer.
Dr. Nirmala Abraham (00:43:09)
So there were a lot of challenges with trying to get the scope more established and that was hard because at the beginning everybody wanted a dumping ground. Yeah. They just wanted to be able to hand it off and we don’t want to deal with this. We don’t want any calls. You just have to handle all of it. So like, okay, again, I am one person. I am literally on call 24 seven I can’t see every single patient that is expected to be seen. Like we have to do more education. Everybody needs to do their part. And I, it was brutal. I mean, I had some people that would just rip me apart for as much as you know, everyone wants to think that physicians are all very appropriate and very polite, very professional to each other. Man, that borderline personality comes right out because if you give them what you want, you are the savior.
Dr. Nirmala Abraham (00:44:03)
If you don’t, you’re Satan. And I had people rip me apart. Well, what’s the point of you? Even being here is just a waste of time and money to even have you here. If you’re not going to do what I tell you to do, like, okay, would you as the surgeon or appreciate having somebody tell you what you have to do? It doesn’t work that way, which as an anesthesiologist, we’re kind of used to that. That is a little bit of what people think they get to do to us anyway. Yeah, but there, there were times where it’s like, all right, I am going to just have to hold my ground because if I don’t, I will get steamrolled in anybody that joins the group moving forward, we’ll just get steamrolled. So it was tough at the beginning.
Justin (00:44:46)
Did you have any low points or points? I’m in over my head and I’m not sure this thing is going to,
Dr. Nirmala Abraham (00:44:52)
Or maybe it’s a Western magic version of that. Oh, there were many of those. Yeah. And
Justin (00:44:58)
Can you maybe tell one or two anecdotes about just some of the challenges you encountered?
Dr. Nirmala Abraham (00:45:03)
Okay. Yeah. So when I first got here, you know, the system was just growing in terms of the employment model and getting people onboarded and all of that. And they hadn’t really onboarded a lot of physicians from outside of the community. Mostly it was acquiring practices that were local. And so, you know, getting my credentialing done and all of that, there were a lot of challenges that came up with that. And they were, you know, just figuring out their processes. They hadn’t really done that very, very much at that point. So, you know, with all of the stresses of getting here, building the new department, trying to get the word out and, you know, trying to figure out what’s going on. I actually broke out in hives. Wow. Yeah. I mean, from the stress. And I, and I was fine. Like, I mean, I was exercising, I was working out, I was doing everything that I could think of to manage the stress, but I just broke out in hives and one of my good friends had done her internship with me here was in primary care.
Dr. Nirmala Abraham (00:46:02)
So I went and I saw her and you know, she gave me some anti-histamines. I was on four different anti-histamines and still totally functional and not at all sedated heavy machinery or not. I didn’t and I still couldn’t sleep. And so I go to the pharmacy to fill the prescription and they’re like, Oh, I’m sorry, your benefits aren’t actually entered in the system right now. I’m like, Hmm. So I didn’t have benefits. So they didn’t have me entered into HR. I ended up not getting my first paycheck because payroll didn’t have me in there. And it all happened like the day we were supposed to open. There was an ice storm. Oh my gosh. Yeah.
Justin (00:46:50)
It’s funny because I’m thinking back to 2010 I was at Villanova in Philadelphia. I’m thinking about, we had the, we called it the snowpocalypse of 2010. I don’t know, I think, I dunno if that hit Ohio at all, but we got like two days in a row where it was like 12 inches of snow both days.
Dr. Nirmala Abraham (00:47:07)
It was just, so this was 10? Yeah, this was 10 going into 11 and I can’t remember, we didn’t get a ton of snow, but we had a lot of ice. But yeah, it was, it was bad. It was bad. And I’m like, okay, I must be all I have to keep telling myself was all right, I must be doing something right because the universe is trying to destroy me right now. So clearly I’m on the right path. I just need to figure out how to manage this. So like little things like that, what happened? I’m like, okay, I’m good. I’ll be fine. Cause there’s a lot about your personality that that’s how you interpret that. Then as things get tough, this is a sign that I need to keep going. Yeah. And people are looking at me like, are you serious about that?
Dr. Nirmala Abraham (00:47:47)
Like, Hey, you know what, this is how I’m choosing to cope with this right now. Because the other option would be to curl up into a little ball in a corner and cry and that’s not me. So we’re going to go with this incident. So yeah, so there were things like that that happened. You know, it was tough building up the patient volume. It just, it took time and the starting over being eight years out of training and you know, just having to build up everything. It was tough because there was that part of me that was like, okay, maybe I do need to just start taking everything and not, you know, screen patients and not be more careful about what I’m letting into the practice. But then I just knew that that was going to set me up for more problems in the future.
Dr. Nirmala Abraham (00:48:34)
So I just made the choice to say, okay, we’re going to stick with our vision, with our plan, with how we want to do things. And then just let that eventually build up into a reputation that makes people want to send their patients here. And it worked, you know, it was, it was not easy at the beginning. And yeah, there were definitely times where I felt like, I don’t know if this is going to go anywhere. I would go to some of the meetings with orthopedic surgeons and the top operating surgeon wouldn’t even talk to me because, and understandably because they’d burn burns so many times by people that had come in and said they were going to do pain management for them and then they didn’t, they would be there for eight months, a year and then they’d bail. And so he didn’t have any faith that this was actually going to play out.
Dr. Nirmala Abraham (00:49:22)
So he was like, man, why am I going to bother? But I would keep showing up at the meetings and, and working with them. And then I had a second nurse practitioner that joined me at the end of 2011 and she was amazing had a ton of experience doing pain management at one of the other hospital systems in the community and mostly on the inpatient side. And so she was helping me looking at the order sets for all the different surgical service lines and kind of revamping things and kind of building up some of the gaps that they had here. And she turned to me maybe two or three months into being there and she just looked at me. She’s like, what were you thinking? I was like, what? And she’s like, this job, what is the matter with you? What, what were you thinking taking this job and taking on all of this?
Dr. Nirmala Abraham (00:50:15)
Like this is insane. I said, well, I just figured when the time was right, the right people would show up and here you are. So off we go. And she’s like, okay, but you’re not like, you’re insane. Okay. Maybe I am, but that’s probably what it takes to do this job. So I’m okay with that. And within a year, year and a half, that same surgeon that wouldn’t even, you know, acknowledge my existence all of a sudden wouldn’t do anything if I wasn’t there. Like, as soon as there was something that had to happen with pain management, he was like, well, what does Dr. Abraham thing? And I’m like okay, well what about this? Okay, that’s good. We’ll do that. And when they had to revamp some policies with extended care and home care and things like that, you know, part of it was going to revolve around how do we make sure that we transition the right pain processes and protocols from the inpatient side to the outpatient side. And he was like, well, Dr. Abraham has to be at that meeting because that’s going to be really important for us to transition that over as well. So that was huge. You know, being able to win someone over like that was really gratifying and it did also then lend a lot of credibility to the work that had been done. So that was, that was, that was a big win.
Justin (00:51:33)
Cool. Well thank you very much for sharing your story, Dr. Abraham. It’s been a pleasure speaking with you. I have one more question that we’ll close with and yours is a pretty remarkable story. I love the fusion of like entrepreneurship and medicine and being able to construct this, this vision that you had. That’s, it sounds like a really unique and exciting opportunity. And I would love to hear just a little story or anecdote about part up a little snapshot into this process when in the midst of, you know, maybe it was like having hives and like the architect doesn’t know what they’re doing. Like a lot of things, there’s a lot of challenges, relationships with surgeons all along the way. There’s a lot of, you know, you said it, like things are just very, very challenging. Tell me about a little snapshot of a moment you had, whether it was with a patient or talking to a surgeon or whatever when you said, you know what, I can see, I think, I think this is going to work. I think we’re going to make it through. I think that there I’m going to see ultimate validation of all of my efforts. Right?
Dr. Nirmala Abraham (00:52:34)
So I mean there’s so many of those that happen at multiple levels. And for me, because I had the academic portion of my life where I did have that opportunity to be a mentor and to have people go through the educational process with me combined with the private sector where I had more of the professional dynamics. I think on the academic side of it, one of the most amazing moments for me was actually this past fall for Asmara. Dr. AnDr.ea nickel, who was the program chair was one of my fellows. And so that was huge for me for actually for both of us and for women in pain medicine because I was the last female program chair in 2007. Wow. And there had not been a female chair for the fall meeting since me and then her. And so that was huge to have her do that.
Dr. Nirmala Abraham (00:53:36)
Cause I was like, yes, it matters. It totally matters that, you know, we’ve got a good strong woman into our fellowship program and got her trained and she is doing so amazingly well at Kansas. And then for what she’s doing and what she’s accomplishing in the academic world of pain management. That for me was just like, okay, what I did, the time I spent academics totally worth it, just completely made that time worthwhile because that is, to me as a teacher, the most important thing is that the next generation that comes up behind me is going to set a good and strong example for what needs to happen and how it needs to happen. So that for me on the academic side was amazing on the, on the professional clinical side. Definitely, you know, like having that surgeon go from not wanting to communicate to feeling like, wow, this is so great to have you here and we want to make sure we keep you involved.
Dr. Nirmala Abraham (00:54:41)
That was a big moment. And there were several like that where you know, the nurse practitioners that I would work with, they’re like, yeah, we’re having such a tough time, you know, getting these doctors on board and getting them to see the value of what we’re doing on the inpatient side. And you know, just being able to communicate with them and having those moments of, look, you know, you remember this patient, you guys were having a really difficult time and they’re like, Oh yeah, you know, this, you know, why don’t you come to our next meeting and let’s talk about what we can do. And so having those opportunities to make those connections and, and help the program advance, that’s, that’s been huge. And I think one of the things that we had also talked about at the meeting last fall was what brings you joy.
Dr. Nirmala Abraham (00:55:27)
And so I was, I was going through my Marie Kondo phase. If there’s something in your life that’s not bringing you joy, then you need to get rid of it. And that’s not the way that most people think of their career. But I also feel like in medicine we have to sacrifice so much to get to where we are. You know, most people are basically picking up the equivalent of a mortgage in school loans, if not more. And that is a huge burden that you carry with you because if this is what you decide you want to do, this is what I wanted since I was 12. I know what that meant at the time. I didn’t know what, you know financially, what that was going to do to me mentally, emotionally, psychologically. I had no idea what impact that was going to have.
Dr. Nirmala Abraham (00:56:12)
But what I do now is if I was not willing to give a piece of me to this job people would be able to tell and it w it would be noticeable. And so, you know, at the beginning, yeah, there is a big part of it, especially now that ends up being about I got to make money, I got to feed my family. I want to actually Dr.ive a car that’s not 15 years old. I, you know, I want to live in an actual house, not an apartment. You know, there’s all these things that you want to be able to transition into. So at the beginning of the career, a lot of times it’s I got to make the most money that I can possibly make. Okay. But sometimes you end up having to do things that are not necessarily in the best interest of the patient or of medicine in general to get there.
Dr. Nirmala Abraham (00:56:58)
And we all know the stories of people that have had questionable ethics and what they’ve done and where they ultimately end up. And my fellows, we, they would ask me about that all the time because especially in LA, there was a lot of people doing shady stuff. And so I would tell my fellows, look, if I find out that you’re doing any of this, I will come to your office. I will snatch that diploma off your wall because I will not have you saying to anybody that you trained with us. And then you’re doing that. So figuring out how you want to live your life, what are your priorities, and then making sure that you pick a position that is going to make sense for you. So if what you want is to be connected professionally and to be involved with education, then you’d go that path.
Dr. Nirmala Abraham (00:57:46)
If what you want is to be in the private sector and you want to have more of a business model and you want to do that then then you look for that. But knowing who you are as a human and then who you want to be as a physician and kind of putting that together is going to be very important because medicine will suck the life out of you very quickly, very quickly with what’s happening right now. And just today I had one of the most amazing little moments with a patient because it’s somebody I’ve been taking care of for a couple of years. I take care of his wife as well and he came in for his procedure and he was like, you know what doc, you are one of my favorite people. I was like, Oh well thanks. And he’s like, no seriously.
Dr. Nirmala Abraham (00:58:31)
He said, you are so happy whenever I see you. You are happy and you obviously love what you do. And he said, you have no idea what a difference it makes to have a physician taking care of you when you’re hurting like this, that really loves being able to do what they’re doing. He said, there’s just not enough people. And he said, you know, it is such a blessing to be able to do something with your life that you really love to do. And, and that’s, and that’s something that is so hard to hold onto in any field of medicine, but particularly pain management because you are constantly faced with people that are suffering and how do you let people know that you care without absorbing so much that it just makes you jaded and burned out and tired. So I think, you know, those kinds of moments when people can reflect that back.
Dr. Nirmala Abraham (00:59:33)
It’s like, okay, then I’m okay. I, you know, for whatever my frustrations have been, whatever my issues with staffing and scheduling and whatever the disaster of the week happens to be, if the patient is still able to see that I have joy in what I’m doing, then I’m still where I’m supposed to be. So that, that little moment today was very validating and very important because we don’t get a lot of positives in medicine. We are always being told what we’re doing wrong and what standard we’re not meeting. So, you know, and in the end, it’s, most of us still go into medicine because we want to take care of people and we want to be able to make a difference in people’s lives. So, you know, being able to know that that’s still happening is, is really pretty cool. Awesome. Well, thank you for sharing with us today.

45 episodes