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Megan Walker: Hello and welcome to Healthcare Online. My name is Megan Walker and today our very special guest from way across the pond is Dr Robert Kayal. Hi Robert, how are you today? 

Dr Robert Kayal: Great. Thank you so much for this opportunity to speak with you and your audience.

Megan Walker: We are delighted to have you. I have seen your book came out recently. And I've been looking into your background and thought, wow, this guy has really been on the move. And I thought your story would be so interesting to our listeners who are based all around the world, all running private practices. So kick us off. Tell us who you are, your background, who is Robert Kayal?

Dr Robert Kayal: Sounds great. Okay, so, my name is Rob Kayal. I grew up in Northern New Jersey, sort of lived in a bubble my entire life in the metropolitan area. As long as I can remember, my Mom has always said that all I've ever wanted to do is be a doctor and specifically an orthopedic surgeon. I don't recall having those conversations, but my mom does pretty clearly.

And I guess it's because I've always loved working with my hands, fixing things. I like to fix broken things in general, whether that be personal relationships problems at the office, or certainly broken bones and broken joints. So, it's something I like to do. I appreciate the instant gratification we get in the field of orthopedic surgery.

You get that reward pretty quickly and you get to get that gratification as opposed to treating, for instance, chronic illness, chronic disease, and just sort of maintaining those conditions your entire career. I tend to fix things pretty quickly and the patients are very grateful, they're able to get back to the quality of life very, very soon after what we do.

So I grew up in Northern New Jersey, like I said. Because I always wanted to be a doctor, I immediately went to college and my degree is actually in pre-medicine, so it wasn't a vague generalised biology or science degree, but it was definitely specific for pre-medicine.

Got into medical school. Did my four years in medical school knew I wanted to do orthopedics applied for the very competitive residency and I was blessed to get into the program and did my training in New York and for the last 25 years or so, I've been out in practice in northern New Jersey. I'm married for 30 years coming up this year.

Megan Walker: Congratulations.

Dr Robert Kayal: Thank you. I have six children who keep me busy for sure. I have a grandchild and a second on the way. So my life is busy. I run a pretty big orthopedic practice, musculoskeletal practice in Northern New Jersey and New York. And I'm currently in the executive MBA program as well at NYU Stern School of Business. Just trying to further my education.

Megan Walker: So when we say busy, that's an understatement. We need a different word for you Rob. That's a lot going on and congratulations on your upcoming wedding anniversary and grand babies on the way. That's so exciting. And so I'm picking up from you and from the research I've done into your background that you have taken a slightly different path to what could be more the traditional work in the hospital or having a singular private practice. I'm sensing an entrepreneurial spirit, which is wonderful. I believe entrepreneurialism in medicine allows the reach and the impact to expand.

So tell me how that came about for you. When did you start going on a growth trajectory and what does that look like in your career? 

Dr Robert Kayal: Yeah. Thank you. I think you nailed it. I think it the entrepreneurial spirit is very strong within it's something that I've always been passionate about.

I've always considered medicine to be a business as well. I don't know if that's taboo to say that, but I believe it's led to my success. Thank God. I treated my practice as a business and I don't mean just financially, you know, the rewards of successful financial business, but all the important aspects of running a successful business, how you treat patients, work ethic, things like that. So to me I've always considered medicine a business and I've attacked it that way. From branding and developing the practice and scaling the practice and adding ancillary services.

I think I got my entrepreneurial spirit from my grandmother. My grandparents came from Syria, didn't really speak any English, and they were into buying real estate and apartment buildings and having tenants. So it really stimulated me to try to replicate the successful business model that I witnessed with my parents and grandparents.

And so coming into practice 25 years ago, seeing patients, I realised at a very young age that because I'm a surgeon, a lot of the days I was in the operating room not really producing any revenue for the practice on those three days, but I still had overheads, I had employees, I had rent, and I started to develop ancillary services.

I started buying and acquiring equipment that would produce revenue, produce follow up appointments for me. For instance, bone density machines, imaging facilities and then ultimately added on more doctors. So that there would sort of be residual income in the practice. There would be revenue that would be generated when I was either on vacation or in the operating room.

We were always producing and then I decided to continue to grow and expand the practice. And everywhere I would go, because of my grandmother, I would purchase the buildings that I would occupy. I would be an owner occupier of my medical building. So I would be paying myself rent.

Guaranteeing a good tenant long term paying, you know, fair market value, but owning it personally, expensing it through the business. So it was a model that I just continued to grow and develop and sort of developed a nice side business as well along the way and having a real estate business. I have close to 20 offices now. So, it's been fun. 

Megan Walker: That's sensational. I'd like you to talk a little bit to the mindset shift that's involved in moving beyond the traditional shackles of private practice. Head down three days in the hospital, two days in the office. There's that really traditional model and then what you've done. What's the difference in your mindset compared with that traditional approach? Can you talk to that a little bit? Because I absolutely love that.

One of the things I've seen in my almost 30 years career as a health promoter is that emphasis on "follow the cow path" we say in Australia, do the same thing as the cow that's gone before. You follow that nice little line. Don't deviate. Stick to this. This is what works. It's a factory model. Stick with it. Now you are over here and it sounds absolutely brilliant and I'm all for it. Tell me about the mindset shift to go from the cow path to what you are doing.

Dr Robert Kayal: Yeah, so one of the reasons I opted to be a physician in the beginning was not just caring for people, which I love, and working with my hands and that instant gratification, but I loved all the other things that come along with being a physician as well, and one of which is autonomy. I loved the fact that I can have my own business, be my own boss, be autonomous, make decisions without having to report to superiors.

That's something that a lot of people, I think, go into medicine for to be a small business owner, at least it used to be that way 25, 30 years ago. Medicine has changed tremendously over the years, as we all know. Now it's becoming much more institutionalised. The days of small, single provider, two or three physician provider practices in those days are for the most part, gone. Most doctors that are coming out of training and fellowships and are joining large healthcare organisations, institutions or large group practices. Unfortunately, the business of medicine is never taught in medical school or in our postgraduate training in our residency or fellowship programs.

And so because it's a business, there's no way to avoid it being a business. Most businesses fail in this country. Startups don't necessarily always do that well, and because we had no formal business training, most businesses fail. So I've always had the mentality of wanting to treat it like a business and grow the practice, expand the practice, scale the practice develop more revenue sources, ancillary services, residual income, revenue sources.

And it's something that I was just always fascinated and excited by, I'm always thinking still today, 25 years later, about growth. Expansion. What's going to be our next move? Do we acquire different practices? Do we acquire different lines of service? For me, the secret to my success was keeping everything in house.

As an orthopedic surgeon, I've always considered myself the go-to primary care doctor for the entire musculoskeletal system. Most people that have a problem with their neck or their shoulder, their hip, their knee, or their elbow, foot and ankle, they don't call their primary care doctor.

They call their orthopedic surgeon, and actually most of what we do is non-operative. People think of us as surgeons. Oh, I don't want surgery. But most of what we do is non-operative. We'll see patients, we'll diagnose them. We will treat them conservatively with injection therapy, physical therapy, acupuncture, massage, you name it.

Most of what we do will be non-surgically managed and, and most of those patients will do well. There are some patients that ultimately fail conservative management or their imaging studies dictate that they do need surgery. But guess what? We're also those doctors that take care of them, so we get to carry out the full circle of patient care. We see them, we diagnose them, we treat them conservatively, but if and when they fail conservative management or they break something, or something needs to be operated on, we're those same doctors that take care of them. So that equates to a humongous database.

For the most part, we are the busiest doctors out there. Because everyone you know has an orthopedic problem and everyone needs an orthopedist. And so because we're so busy, 25 years ago I made the decision that I'm not referring anything out. I'm going to keep it in-house. I'm always going to do what's best for the patient, obviously. But if there's something that I identify at an early stage of my career or identify at an early stage of my career that I was referring out regularly, I would hire that doctor. I would hire that specialty. I would cherry pick the best in the industry and hire that and keep it in house.

And over the last 25 years, that's led to every specialty of orthopedics. And we've gone wide. And then because we've gone wide, we've then gone deep with having backup. I call them an incredible roster. You know, like a deep bench in baseball where I just have multiple expert surgeons and specialists to treat different conditions, which is allowing us to continue to expand our footprint as well. I don't like to give away business. I think it's just bad practice. There are patients, our patients want to stay in our practice, so because of that we've generated so much imaging, CAT scans, MRIs, chiropractic, physical therapy, pain management, spine cases, epidurals, you name it, we've done so much, but all of that is inhouse.

So at the Kayale Orthopedic Center, everything is kept in house and so patients love it. We call it the one stop shop for all your orthopedic needs. Patients love that service same day. They don't have to book other follow up appointments anywhere else. A patient can actually come to our practice, get seen by a doctor, get their x-rays. If they need any injection therapy, they can get it the same day. They can go get their MRIs, their CAT scans, their physical therapy, whatever they need. They'll get it often the same day. So it's a very concierge, boutique like medical practice, which has really fascinated people because it's not something you see anywhere.

So that's what really led after doing this massive growth, massive expansion over the last 25 years. Every year I would reach out to my billing department and I would say to Yulia what are the reimbursements? What's going on? What's happening this year? 

I've always kept my finger on the pulse. It got to a point in 2021 where you can imagine having 20 offices, 350 employees, probably over a hundred healthcare providers. The overheads to run that practice was exorbitant and with declining reimbursements year after year, were getting squeezed by insurance companies and increases in overhead.

I wanted to make sure that this practice would be sustainable for many, many years to come. So I remember watching Shark Tank one night with my wife. We would watch that regularly before going to bed. I've always admired the entrepreneurs and I said to her, you know, I'm going to take my practice to Shark Tank.

I need a shark because we have this model that is incredibly unique. I want to take it across the country because I know how to do it. I know how to scale it. Doctors know nothing about business, but I can do it. So I didn't take it to Shark Tank, but I took it to market and I had multiple offers on my practice, and I decided to do a joint venture with Robert Wood Johnson, Barnabas Health, which is the largest healthcare system in the state of New Jersey.

I needed a shark. I needed a partner to help negotiate better contracts, better rates with payers. Because as big as we were pale in comparison to the size of a humongous healthcare system that can actually sit down at the table with Horizon Blue Cross Blue Shield, Aetna, UnitedHealthcare and negotiate the best payer rates.

We take care of a lot of lives and so I needed that support. And now that I did that, I've guaranteed the sustainability of the practice and the security of the practice in our employees for many, many years to come. 

Megan Walker: This is a mind blowing conversation. I love it. What's come to mind is another entrepreneur I spoke to recently who said, the answer is no until it's yes.

And I love that you are about the yeses and not about the, oh that's too hard, it's too expensive so we better stop here. We better stay small. I just love it that it's just a series of yeses. And what's the next yes. That's so positive and uplifting. So you must have a lot of clinicians (and I'm leading to you creating your book) say, how on earth are you doing that? Teach me, show me. Over to you. This is the entree for the demand for people wanting to be like you. 

Dr Robert Kayal: Well, you know, I just love what I do and it's something that I just wanted to share with everybody.

I also want to build a great succession plan for this practice. I want to take care of my doctors that have committed to this organisation and to help grow this organisation with me. I certainly could not have done it alone. So I just want to share my knowledge and skillset and try to help doctors out there that are struggling because I know there are many doctors out there that have made decisions to sell out their practice or join an institution, and it's not exactly why they went into medicine in the first place. You know, it's just the nature of the beast. The government makes it very difficult to keep our heads above water.

Especially after covid, the re requests from employees for salary increases and working from home and things, it's just overbearing for most people, and so they give up and say, you know what, let me just be employed. I'll just be happy being employed. But that's not why they went into medicine. They went into medicine to be the quarterback in the doctor patient relationship, to be able to have those relationships and really be there for their patients and never say no and care for them.

But we're dictated. There are so many things that the government imposes, like the electronic health record and the notes have to be this way and you have to spend this amount of time, and half the time we're spending talking to a computer instead of the patient or our back to the patient, it's so rude and disrespectful.

You know, there's no time to establish those relationships that I've enjoyed my entire career, getting to know all my patients and speaking to them about their families, their husbands, their wives, their kids. Where are you going on vacation? Oh, it's so nice to see you again. It's volume, volume, volume, volume, volume.

Now you have to do so much volume because the reimbursements are so poor. But yet everybody wants a raise every year. And you have to give them what they want, otherwise you're going to lose them to the large institutions that are surviving from donations from locals that are supporting those hospital systems.

So it's a very difficult and competitive market. So you have to be preemptive in your approach. You have to be constantly on the prowl looking to how you can grow your practice . Is there a new service that you can provide in inside the practice that you're not currently considering?

I consider the Kayal orthopedic center my golden goose. Everything else is additional revenue. But if I don't take care of that golden goose. My patients would support everything else, every other service line, you're going to fail. Now, I know a lot of doctors over the years that,  I'm just a back doctor. I don't take care of anything else. You know, if you have a shoulder problem, go here, go there.

But why not hire a spine surgeon or hire a knee surgeon, or why don't you replicate my model? People don't take risks, that's the problem. Any return? Most of best returns are the riskier investments. So I understand you have to have stability and, you know, you know, take a certain amount of conservatism in your approach, but in order to distinguish yourself and to differentiate yourself from your competitors.

Maybe not even that. Just to keep your head above water, you have to think outside the box regularly. It's just something we have to do. It's a business and I emphasise that a lot in my book. 

Megan Walker: So tell us about the book. What's it called, who's it for? What will they gain from reading your book? 

Dr Robert Kayal: So the book is called "Mastering the Business of Medicine and the Doctor-Patient Relationship: From Solo Practice Entrepreneur to Orthopedic Empire". And it's a book that honestly I wanted to write for over five years, maybe closer to 10 years. And I just remember last Christmas, I was flying home from my happy place. We go to the Caribbean. I love Turks and Caicos, and I'm sitting on the plane. It's a three hour flight. There was no internet and I'm just that person who can't waste time. I don't really watch TV unless it's a documentary. I like to be educated all the time.

So I live my life by my list. So I pull out my computer and I can't do emails, I can't do that kind of stuff. I look at my things to do list and one of them was write a book about the business of medicine. And so I'm like, you know what? Let me at least put an outline together.

And so I put an outline together. I think there are like 11 bullet points. And that took about five minutes. Very shortly thereafter, I just started to elaborate on all the bullet points. And I swear, I think 95% of the book was, I mean, it's a short book, it's 115 pages or something like that, about 95% of the book was done by the time I landed. I couldn't believe it but it just came out so easily. Then I spent the next couple of weeks or months editing it grammatically, you know, responding to the publisher.

But the contents of it came out very, very quickly. 

Megan Walker: It was already within you because you'd already delivered it and worked it. That's fantastic.   

Dr Robert Kayal: So it's really for every healthcare professional and actually entrepreneur too. It, it doesn't have to be for a healthcare professional. Yes we talk a lot about how to build a medical practice. And that medical practice can be a physician, a physician assistant, a nurse practitioner, a physical therapist, an acupuncturist, a nurse. It could be anyone treating patients, because I do talk a lot about the attributes that one needs to possess.

If you are considering a field in healthcare and if you want to succeed, well, you sort of have to be this way. But you know, you have to be kind and considerate and compassionate and empathetic and conscientious. You have to put your patients first. There's so many attributes that we can talk about in order to be a successful healthcare professional.

But I do also talk about basic fundamental principles about how to succeed in business too. You know, with that old school traditional work ethic, which is unfortunately not commonly appreciated much these days in the newer generation of people. You know, I'm an old school traditional, like killer work ethic.

I've been in practice for over a little over 25 years now. I told you I'm going to school, get my MBA. But I'm still the busiest surgeon in the practice. I'm still seeing the most patients, I'm still doing the most surgeries. I'm running the entire practice doing all the business development.

I have six children, a grandchild, so my, my schedule is packed, but it, it's just something that is in my DNA. 

 And I just encourage a lot of people out there. It's nice to have goals and aspirations. Say, I want to do this, I want to do this, but you really have to be a certain type of personality.

You want to go into investment banking. It's like being a doctor. I mean, to be an analyst and to put in those hours, you have to know what you're getting into and getting into a medicine it's like you're sacrificing a lot of things. You really are for your patients if you are doing it for the right reasons.

And I talk about that. You know, some people do it for the money, the wrong reason. I mean, it's a bonus. It's really nice that the salaries of physicians are well above average, but you'll fail if you're doing it for that reason. You know, so there's so many things I talk about.

We mention the seven Cs in the book, but I character conduct conversation, you know, being conscientious and others that I think are important. So we talk about a lot about your character attributes, work ethic and really your heart. You know, do you ever really have a heart for people? Are you in your profession for the right reasons? You got to love what you're doing in order to succeed, and that's why I love orthopedics still so much. 

Megan Walker: Oh, you can see it and hear it. It just comes through you so naturally that you were tapped on the head and designed to do this work, which is wonderful.

So I'm going to put a link below where everyone can go and check out your book and get their hands on it. And what's your advice for other clinicians, even therapists and practitioners who are hearing you and going, oh wow, this guy's cool. He's r a go-getter. He's out there. What's your advice for those other clinicians who want to achieve broader impact, but maybe a little, perhaps if I could say this a little too risk averse?

Dr Robert Kayal: first and foremost, you have to understand what your purpose is in life. And discover that gift that you were blessed with and use it so that you're actually giving back to the world in some capacity. You have to be doing healthcare for the right reasons. You just really have to understand what your purpose is in a life.

And I think that's really important to consider because this life is short. And we're blessed with this life for a purpose and for a reason. And for me, I'm a Christian. I understand His will and purpose for my life is to honor and glorify him in all that I do. So for me, my practice is my mission field.

I don't consider this to be my practice. It's God's practice. I was blessed with it. I'm a steward of this incredible practice that he's blessed me with. But because of that, I'm very much accountable to him for what I do with this practice. And so I would just encourage everyone to really think about their lives what their gifts are, what their purposes in life, and go for it.

For me, when I sign my book and give it to everybody I write the Bible verse Colossians 3 23 to 24, which says, in whatever you do, work at it with all your heart, as working for the Lord, not for human masters. It is the Lord God you are serving.

And so for me, that's sort of my motto. I'm working every day. I put my heart and soul into this practice because this practice can be used to honor and glorify God in so many ways. As a surgeon, I'm gifted with the surgical expertise. I can help people that way. I can help people financially. If, if some of my 350 employees runs into a bad situation, they need me, I can give to charities because he's blessed me with this practice.

And you know, there's so many things I can do with this practice. So what I would just encourage that whatever you do. It's again, this book's about healthcare, but the book's also about being an entrepreneur and being a business owner. But that business has to have its purpose. It has to be successful to be used for the betterment of society and in my world that is serving God. And so that's what I like to do and that's what I encourage you to do. 

Megan Walker: Well, what a spectacular conversation. Robert, thank you so much for sharing your wisdom, your passion, your love, your humanity. I wish you all the success and all the stages in the world where you can share this and if you change your mind and you don't feel like doing so much orthopedic surgery, please consider motivational speaking for clinicians. 

Dr Robert Kayal: Well, this has been such a pleasure, Megan, talking to you. I really appreciate you so much and the invitation. It's been an honor and absolute pleasure to talk to you.

Megan Walker: Great. Everyone by Dr. Dr. Rob's book and we look forward to staying in touch and following you on social media. We'll have those links below as well. So thank you so much, Rob. 

Dr Robert Kayal: Thank you so much.

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