Who profits from Obamacare? It's not patients, and it's not physicians

This link from the NY Times highlights an important point about current health care changes - they are shifting money AWAY from care, and TOWARD support of infrastructure

Physician salaries are going down, and accordingly, so is the incentive for talented people to go into medicine, or stay in medicine.  Physicians are retiring early, sometimes as early as in their 30s.

On the other hand, administrator salaries are increasing, and outstrip that of physicians.  According to this NY Times article, the average hospital administrator makes 43% more than the average family physician.  Does that make sense to you?

It's important to remind patients- buildings do not take care of patients.  People do.

The Power of Choice: Lake Bell, Bill Simmons, Rick Gottlieb, and why patients should care about the Long Tail

I was listening to a fantastic BS Report Podcast with Bill Simmons, where he was interviewing the actress Lake Bell about the upcoming movie "Million Dollar Arm".

For those not familiar with the movie, it's a true story of how a baseball agent/scout (played by Jon Hamm) travels to India and arranges a contest to find young Indian cricket players to come to the USA to play baseball.

During the course of the interview, Bill Simmons was noting Lake Bell's interesting career, where she initally had a traditional Hollywood actress pathway of some marginally-successful runs on TV shows and movies, despite being clearly immensely talented.  She has found a new pathway to success, through things like the Emmy-winning web series "Children's Hospital."

Bill asked her at one point in the interview if Lake was interested in "getting on real TV."  Lake gracefully laughed that she actually preferred being on "fake TV."  This was a fascinating conversation for several reasons, which I'll highlight here:

1. Lake very appropriately realized that Hollywood was not savvy enough to take advantage of her talents, and she sensed a market inefficiency.  In particular, she noted that only a small % of movies are directed by women, even though they do a high % of movie ticket purchases.  FiveThirtyEight had an excellent blog post about this a few weeks ago, noting that this is a true inefficiency - Hollywood would do better financially if they took the women's view into mind more.

2. Lake had one area of particular passion, which was voice over work.  She noted that there is an enormous bias that has men do the vast majority of voice over work, and she struggled to find such work as a woman.  She took a brave and pro-active approach to correcting this- she made her own independent movie about a woman struggling to get voice over work, called "In a World" which parodies the ubiquitous movie trailers that begin with that phrase.   Check out the very funny trailer here.

3. A super important point here- Lake is VERY successful.  She is not on a network TV show, but she doesn't WANT to be on one.  Instead, she's on an Emmy-winning web series, directing her own movie, about to come out in a big studio movie, recently married, and happy.  She created her own pathway to success.

4. What's incredibly ironic is that this line of questioning is coming from Bill Simmons.  For those not familiar with Bill Simmon's back story, he is often cited as the single most successful individual who has parlayed non-traditional media to create an empire.  He started writing a small web column called "Boston Sports Guy" back in 1997, when there really wasn't such a thing as a web column.  He created a great product, and eventually moved up the ranks through ESPN.  He has been called the "Most Influential Man in Sports Media" by his competitors at Sports Illustrated, and ESPN made him the editor in chief of their influential Grantland website.  In full disclosure, Grantland is my favorite website, and I'm a huge Bill Simmons fan.
     So, what's incredibly ironic is that if there was one human being on the planet who should appreciate that success shouldn't be defined by having to participate in traditional products, it's Bill Simmons.  

Yet, he fell into the trap of assuming that there is only one pathway to success.

Segueing .... in the excellent book The Long Tail, Chris Anderson notes that the trend in the current economy is to offer people choice.  The long tail in the title refers to the shape of a Pareto distribution (see picture above).  The concept in the book is that in the past, consumers had limited choice, and the bulk of sales occurred on the left side of the graph.  For example, the vast majority of books sales were the top 20 best-sellers, the vast majority of record sales were on the Billboard Hot 100, etc.

However, because of services like Amazon.com, ITunes, and (obligatory Microsoft reference) Bing search, consumers have access to far more choice, corresponding to the "Long Tail" on the right side of the curve.  And we LOVE it!

For example, I grew up consuming traditional media.  I read my local newspaper everyday (the Trenton Times), listened to Top 20 radio, and watched The Cosby Show and Facts of Life just like everyone else.  It was ok.

Now, I consume media I really enjoy.  I read my medical websites, but also enjoy Grantland, FiveThirtyEight, but also websites for my favorite niche sport, Mixed Martial Arts.  I listen to lots and lots of Podcasts, which is my favorite form of media.  And I hardly watch TV or listen to radio.  It's a completely different way of consuming media, and I vastly prefer it.  Choice is simply better.

This applies to all walks of life.  I love Chipotle.  That said, I am really glad that Baja Fresh and Qdoba exist.  I love that we have a choice.  Even if you go to Taco Bell, they've had to improve their game because of the competition created by Chipotle.
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So, what the heck does this have to do with healthcare?  Well, in every other facet of life, the trend is to embrace the Long Tail, and offer consumers choice.  But the trend in healthcare is in the OPPOSITE direction, to limit choice.  This is not good, and as a consumer, this is not what you want.

One popular model is that idea of a "narrow network", where a large employer or insurer will contract with a limited group of providers, and the consumers will have to use the provider that is within that narrow network.  This, in my opinion, is definitely not in the best interest of the consumer.

I'll give a very specific, real example of how this hurts patients.  On Friday afternoons, I perform my spine procedures at the Overlake Surgery Center in Bellevue.  When I perform procedures, in the operating suite next to me there is another physician who is also performing spine procedures.

He's a great guy and a great physician.  He is so awesome, in fact, that I am going to advertise on his behalf on my blog- his name is Llewellyn Packia Raj, MD.  While I suppose he is technically a competitor of mine, I don't view him that way.  I view him as an amazing, compassionate physician, with great technical skill and wisdom.  I sincerely want him to be successful.  I'd gladly see him as a patient, and would send a loved one to see him.

It is my personal belief that for some patients, Lew will be a better choice, and for other patients, I will be a better choice.  While I think we are both very good at what we do and have some overlaps in skills and personality, I don't think we are equivalent. 

So the question is- who gets to make that choice?  The consumer, or some central agency defining a narrow network?

To me, this is obvious.  The consumer, in this case the patient, should make the choice.  That should be their right, and helps lead to a better fit.

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For the final leg of this blog post, I'll comment on a time I deliberately chose to escape a narrow network, and how happy it made me.  When I moved to Pittsburgh, I needed to establish a relationship with a new dentist.  My dental health plan had a narrow network, so I was looking for a specific dentist within that network.

I happened to have a patient who was a brilliant periodontist, and he was someone I also related to on a personal level and trusted.  I asked him who I should see, and he recommended a great general dentist named Rick Gottlieb.  

Dr. Gottlieb was out of my network, but my friend said that Dr. Gottlieb was so good he'd be worth paying cash to see, and gave me some anecdotes on how this would save me money in the long run.  This was a big leap of faith for me- I had never willingly paid cash for something for which I insurance, but I trusted his advice and saw Dr. Gottlieb.

I am so glad that I did!  Rick was far and away the best dentist I had ever seen, and I consider him the best clinician I've ever been to.  I found the experience exceedingly pleasant (..... how often to people say that about going to the dentist!), and I felt confident about my dental health.  I thought it was the best run office I've ever been to, and I've used it as a model when I think about how Garrett and I should run our office at Lake Washington Sports & Spine.

In terms of cost- I think my friend was right.  By helping educate me about my long term dental needs, and helping prevent expensive long term periodontal care and other advanced procedures, I am likely going to save thousands of dollars in the long term.  Now, from an insurer's view, they may not care.   They don't care about savings 15 year downstream, and they are willing to be penny wise, even if it's pound foolish.

But here is an even more important point that is lost in the cost-savings debate- I really like Rick as a person.  That means something to me, and it has value.  Rick and I were social acquaintances when I lived in Pittsburgh.  I don't know that it quite reached the level of "friend", but it was meaningful to me, and I knew very clearly that he cared about me as a person and was rooting for my interest, beyond me merely being someone who provided him income.

And I think that this is something that is getting lost in medicine in all of the discussions of cost containment, narrow networks, meaningful use, and similar blather.  Medicine, at it's core, should be about the relationship of the patient and their physician.  Like all relationships in life, you can make a best guess, but ultimately finding the right match is a give and take process, but when you find that match, it's wonderful.

To that end, I encourage physicians to take a stand and fight for patient choice.  There is some risk in that process- you will lose some patients.  But I am ok with that- even more than that, I embrace it!  If someone chooses to see a great physician like Lew Packia Raj instead of me, that is their right, and more importantly, that frees up my schedule to find a patient who is an even better match for me.

...... I can just see the movie trailer now - "In a world, where patients have a choice ....."

Wonderful link about the power of being mindfull

I absolutely love this link on the Huffington Post about the power of being mindful.

I love my current patient population.  I work with some incredibly thoughtful, creative, and active patients.  One common trend I see, however, is that because they so talented, they are often spread thin, and they have too many responsibilities.

I certainly relate, and one of my main motivations for leaving academia was to create a simpler life for myself that focused on what I considered really important, which was family, health, my dog, nature, exercise, and kindness.

I think there were some key elements the author hit that I think are essential for health:
1. Stay on task.  We can't actually multi-task.  Very smart people can give the illusion of multi-tasking, but multi-tasking creates a drag on efficiency, and it's exhausting.

2. Allow your mind to wander.  Build time into your day to do nothing.   Practice meditation to really embrace that nothingness.

3. Get outside and walk.  This is the greatest gift my dog Bucky gives me (..... besides his love, of course) - reminder that the way we are biologically designed to discharge our autonomic nervous system is by getting outside and walking.  While Bucky may be more animated when he starts getting fidgety from a lack of exercise, humans have the same autonomic reaction.  We need that discharge to recalibrate our system.

4. Enjoy the moments and reflect.  I find this especially enjoyable living in the Pacific Northwest.  Living in such a lush environment with water, flora, and mountains is beautiful.  Take time to enjoy it.  It's such a privilege to be around so many bright, thoughtful, and varied people.  Express gratitude for living in a world where you can engage with them.

Embrace simplicity!

How Obamacare forced a two-tiered system

There is an excellent piece in the Wall Street Journal that explains how the ACA (or as everyone knows it, Obamacare), has forced a two-tiered health care system.

One of the key things to recognize is that physicians did not choose this model, we are just predictably reacting to it.  I know that I, and many physicians I know, warned that Obamacare would DECREASE access to physicians.

The heart of the matter is two-fold:
1. Absurdly low payment.  The Center for Medicare and Medicaid services has acted in a bullying, unreasonable manner in terms of the extent and levels of their cuts.   They were already paying lower rates than private insurers, and they continue to cut rates to levels that are unsustainable.
      Giving some specific examples, one of our most commonly performed procedures is an ultrasound-guided injection.  Medicare was already paying less than other insurers, and then cut payment by another 61% at the beginning of 2014.  This was not a negotiation, mind you, they simply made the unilateral decision to cut payment.
     Similarly, as my colleague Ethan Colliver noted in his excellent interview, cervical epidural steroid injections, depending on setting, are paid $40-50 per injection.  This is less than a massage therapist makes, and this is for a potentially dangerous procedure that requires a high level of skill.  In many cases, this may not even cover the cost of our liability insurance to perform the procedure.
      It is not hyperbolic to say that the Mafia is more generous in their interactions with their "clients."  I know that patients in the Medicare demographic are amongst my favorite patients.  This includes people like my parents, or some of my favorite patients like Margie McMaster, with whom I promised I would grow old together.

2. Increased compliance costs.  Medicare money is dirty money- it comes with a level of requirements that no other payor demands.  The most egregious aspect is that Medicare uses "Recovery Audit Contractors", who are bounty hunters that review physician charts to find ways to deny payments, threaten physician licensure, and potentially criminalize physicians who are trying their best to meet the compliance requirements set by CMS.
       In addition to the unpleasantness of being forced to click buttons instead of listening to patients,  it creates a sense of paranoia that no matter how hard we work to be in compliance, small errors could lead to devastating financial penalties that are out of our control, or an inability to continue practicing as a physician.
       Physicians have attempted to adjust to the increased compliance requirements by taking hundreds of hours of continuing medical education to learn more about Medicare requirements (..... time that otherwise could have been spent learning more about how to treat patients- think of the opportunity cost!), and this is problematic for Medicare.  We are not supposed to succeed!  Medicare is underfunded, and now depends on fining physicians to stay solvent.  So they introduce increasing complex regulations, like ICD-10 (which the new diagnostic coding system), realizing that if they make it impossible for physicians to comply, the don't have to pay physicians there already substantially cut fee schedule.

The combination of low pay and deliberately unworkable compliance system is untenable.  For many senior physicians, the solution is to retire early.  For others, it's to leave medicine.  For many future doctors, the decision is to not enter medicine in the first place.

..... and for the very best physicians, who have a choice in the matter, it's stop taking Medicare.

Patients, however, have a choice.  If you didn't like your experience with a commercial insurance carrier like Aetna, Premara, Regence, Cigna, or United, you could write to the insurance company leadership and let them know that low-balling physicians and increasing their compliance requirements hurts you as a patient.

It so happens that for Medicare, your "insurance administrator" is your congressman.  So write them!  Let them know that what they are doing to physicians is not right, and it causing you to lose access to the best doctors.   Congress has made it clear they don't care what physicians think.  Hopefully, they do care about patients, since ultimately, they work for you.

Meet the Experts: Ethan Colliver, DO

Gary: For our next feature, I am excited to introduce Ethan Colliver, DO.  Ethan, for introduction, can you tell us more about what you do?

Ethan: Sure. Thanks for having me Gary.  I am a fellowship-trained physiatrist specialized in treating Sports & Spine Disorders.  I use diagnostics such as X-rays, MRIs, Ultrasounds, and a functional exam to diagnose a problem and then use a host of treatments such as medications, manipulation, injections, or exercise to alleviate the problem.  

Gary: Many people treats spine and sports conditions.  What makes your approach different?

Ethan: Physiatrists are the Function experts, so I measure the patient's success by how much function they have gained by coming to me, and not necessarily what number they say their pain score currently is.

Gary: My experience has been that some physiatrists make that claim, but in practice they function similar to other physicians.  Do you think you provide a similar experience to other PM&R physicians, or do you do specific things to make sure you legitimately prioritize function?

Ethan: Absolutely.  I have adopted functional tests from great mentors or functional exercise classes I have attended to measure a patient's function.  For example, I can quantify a patient’s ability to do a full squat and use that number to measure their improvement.  I will measure a patient's function, strength, and flexibility throughout their rehabilitation program; if their pain has improved but their function is still lacking, then I will recommend they continue the rehabilitation program.  I prefer this to questionnaires which are subjective.

There are examples where the patient's Physical Therapist has recommending discontinuing therapy, but I felt continuing it was needed to work more on functional goals. Also, one of my most useful tools is a Co-visit, where the patient, physical therapist, and I get together to go over the exercise program in detail and see how we can make it better and more efficient for those patients who are struggling.

If you ask me, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  All other treatments just make that transition easier. 

Gary: I find that patents really have a hard time grasping what "function" means.  What do you mean?  How does that affect the patient interaction?

Ethan: We discuss with the patient multiple levels of function ranging from a very small scale such as a "dysfunctional" vertebra or one "out of alignment" that can be treated with manipulation; to a kinetic-chain level of function where lack of hip flexibility and strength is causing back pain; to a community level of function such as returning to work, sport, or exercise program.  Our interactions and goals are centered on returning function at each one of these levels.  

I use my specialized training to assess someone's kinetic chain.  I determine where their chain is restricted or not working well, and develop a rehabilitation program to restore function to the chain.  For example, this allows me to tell someone that their back hurts because they have significant hip stiffness, and that if we work on improving hip flexibility and strength then the back pain will improve.

Gary: You mean to say that doing a "pain- relieving" injection, such as an epidural steroid injection, is not enough for someone with back pain.

Ethan:  Exactly.  Almost all treatments for back pain are reactionary.  That means we wait until the patient has pain before we treat.  That treatment may help for a while but if the patient continues to have major restrictions in their kinetic chain like a stiff hip, then they will continue to move in a way that puts stress on their back.  Eventually, their back pain will return.  Improving the patient's flexibility and strength through a rehabilitation program is critical to reduce their chance of future episodes of back pain.  Again, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  

Furthermore, patients are mistaken to think surgery on their spine will “fix” them.  It’s like putting new tires on a bent rim of a car.  You can fix the worn tires but if you continue to drive on the bent rim, then the tires will go bad again, real quick.  This is one reason why people have repeat spinal surgeries- they never fix the underlying issues leading to their back pain.

Gary: When I was contemplating making a transition from academic medicine into private practice, you were one of the first people I spoke to.  You correctly made the observation that I was really making a transition from a large system into a smaller practice model, and that you had made a similar decision successfully.  Tell me more about what you perceive as the differences between large systems and small, independent practices?

Ethan: In a large system, I found that all the clinicians were compartmentalized. I was "The Spine Specialist" and only saw back and neck pain; while this doctor over here was "The Shoulder Surgeon" and only saw shoulder pain.  This approach fails because you may have to treat someone's neck to treat their shoulder pain, or vice versa. Small independent practice allows me to treat the whole patient and not be myopic on just their neck or back pain.

Large systems are like large ships, they are hard to start moving and are slow to change direction.  For example, when I gained expertise in using ultrasound, I couldn't get access to an ultrasound machine because of the bureaucracy.  Or when I needed to add more or less time to my schedule for therapeutic injections, it took a long time to happen, which ultimately hurts patients. Now, I can more efficiently change my schedule or access to new technology or treatments because I have a small clinic.  

Gary: Do you feel you can help patients more, now that you are in physician-run small practice?

Ethan: Yes.  Like small business, small medical practice is where a lot of innovation in medicine takes place.  We can try new emerging treatments more readily.  Some may work, some may not, but our size allows us to quickly adopt changes, where it can take decades for large institutions to implement change. 

Gary: The national trend is clearly for physicians to go in the opposite direction, leaving small physician-owned practices into large systems.  My sense is that this is motivated by fear.  What's your perspective?

Ethan: I think this trend is multifactorial.  I have seen examples of physicians near retiring who think joining a large institution will take away the administrative duties of a small clinic.  I have seen examples where the doctor joins a system because they feel that the system can cover the cost of running the clinic in hopes of making the physician more productive.  The most troubling reason is for fear that if the physician does not join the big system then the physician will not get to see any patients because the big institution will only let their "own physicians" treat "their patients".  This approach is growing in many areas of the country, even though it is illegal.  The difficulty comes in proving an institution is using this approach.

  

Gary: Why do you think physicians are so risk averse?  How much of this do you attribute, for example, to student loan debt?

Ethan:  Multiple things make new physicians risk averse about starting a practice.  Student loan debt is a huge burden.  My own loans were around $250k and after 30 years of payments would be over $500k.  I have met retiring physicians who paid for medical school while working minimum wage jobs in medical school.  No wonder many earlier physicians opened their own practice - they didn't have much debt.  Nowadays, banks think twice about lending money to open a practice if the doctor already has $250k of debt. New physicians worry about how they will pay this mountain of debt, so they join large institutions that promise to pay some portion of the loan debt.

Also, most small businesses are not started by business majors, they are started by engineers, doctors, cooks, photographers, etc.  These people seldom have a background in business.  Not having this knowledge is seen as a big barrier for new doctors thinking about starting a practice.

Gary: One thing I love about private practice is the freedom to be innovative.  For example, you and I have shared ideas on novel ways to help patients, and my main "barrier to implementation" is running it by my partner Garrett.  I like running things like Garrett, because I think that adds a reasonable level of vetting to make sure something is a good idea.  What are your thoughts about innovation within private practice?

Ethan: Like I mentioned earlier, small practices are the "laboratories" of innovation.  Their size allows them to quickly measure the efficacy of emerging technologies and treatments.  Large institutions take a long time to adopt these changes only after small practices have shown these changes to be efficacious. 

Gary: I know you and I have talked off line about our concerns about how insurers are making decisions about reimbursement that are going to hurt patients.  The particular example that, to me, is the most striking is Medicare reimbursement for cervical epidural steroid injections.  Tell me more about your thoughts on this?

Ethan: Medicare and other insurers are pushing to make health insurance cheaper by trying to cut payments to providers.  A physician now gets $40 for doing a potentially dangerous cervical epidural steroid injection for someone with severe neck and arm pain.  Many physicians and institutions cannot afford to keep providing potentially dangerous treatments under such conditions.  I think two things will happen. 

First, the great institutions and physicians may choose to stop treating patients with this insurance because "it's just not worth it"; second, someone less trained and less-qualified such as a CRNA or NP may start doing these procedures at a reduced reimbursement rate.  In that case I think you will get what you pay for; fewer patients may improve and more dangerous complications may occur.

Patients trust doctors with their lives.  Already, a UPS driver can earn more than a physician over their working lifetime when you factor in the physician did not earn meaningful income for 14-15 years while training to be a doctor.  Why would you want to push away the smartest and brightest minds from going into medicine by decreasing their income incentive and replacing them with less trained, cheaper labor.  I don't think it makes sense.

Gary: I feel like a real barrier is that patients love the idea of free or government sponsored healthcare, but are not fully aware about how restrictive this is for medical decision making, and how it can adversely impact their health outcomes.  Do you think patients really understand the restrictions placed by insurance?

Ethan: Socialized medicine and Capitalistic medicine both have their pluses and minuses.  Socialism can offer some degree of basic services to everyone, but most great discoveries in medicine occur in the USA.  Capitalism encourages innovation and compensates the innovator accordingly.  The more healthcare is run by the federal government, the less innovation will occur, and the more the brightest and smartest will steer away from medicine into more rewarding careers and lead the United States away from being a leader in Medicine.  I think that is a mistake.

Gary: So, let's say that tomorrow I can appoint you as "Health Czar." What do you do?  Notice, by the way, I am deliberately not calling you "Health Insurance Czar"

Ethan: Most diseases today are due to lifestyle: obesity, high cholesterol, hypertension, diabetes, heart disease, etc. I think education and encouraging healthy lifestyle changes would be more effective and cheaper than treating a person who is already sick.  Proverbs 22:6 says "Direct your children onto the right path, and when they are older, they will not leave it."    Schools and parents can have a great impact on children by choosing healthy food options, removing junk food vending machines, promoting athletics and physical education.  The Surgeon General in 1960's has effectively decreased the smoking rate to the lowest level in 50 years and had a great impact.  Why can't we take the same approach to eating and exercise?

ActivAided in the News- Kelly Collier: "Saving the World, One Back at a Time"

This is a great news story about Kelly Collier, who worked with me to develop the Recovery Aid back brace by ActivAided.  I'm the physician mentioned in the story- Kelly and I met when we were both working in Pittsburgh

Some highlights from the story:
"Inventor Kelly Collier first connected with Innovation Works to build her business skills. She had just finished a dual degree in materials science and biomedical engineering from Carnegie Mellon. As part of a class project -- and with guidance from a physician recognized as an expert on spine care and sports medicine -- Collier developed a device to ease back pain. With the makings of a prototype, she then faced challenges with business development. 

"It was hard to convince people to believe me," recalls Collier. "And to get people to believe that this product was going to work the way I said it was going to work."

She attended free public sessions and applied for Innovation Works' AlphaLab program, a business accelerator that funds entrepreneurs with a $25,000 investment and provides intense business mentoring. Collier then obtained additional funding from Innovation Works as her business, ActivAided Orthotics, grew. The RecoveryAid garment is now sold online and through medical supply companies across the country.

"The product works really well," says Collier. "My goal was to try to save the world one back at a time." 

Edge & Spoke: Lessons learned from a great local business

As small business owners, we here at Lake Washington Sports & Spine like to observe the success of other small businesses (even outside of medicine) as models for how to treat our patients.

One such business is my bike shop, Edge & Spoke in Redmond.  Edge & Spoke has recently rebranded from their prior name, as the former store manager Brian "Venny" Venable purchased the shop in early 2014.  

I like to think of Edge & Spoke as "my bike shop."  As a cycling enthusiast, it's nice to have a shop that you think of as your home base.  I've lived in other communities where I did patron a local bike shop, but did not feel a kinship with the management.  Rather, they just happened to be the bike shop closest to where I lived.  I don't feel that way about Edge & Spoke.  To me, they feel like part of my cycling family, and I know that if I have a cycling need, they are where I will go.  

Here are some lessons I've learned from Venny and his team about how they do business, and hope to bring to our business at Lake Washington Sports & Spine:

1. Sales through service:  

      I first met the Edge & Spoke team one year ago when I first moved to the Redmond/Bellevue area.  I was looking for a new commuter bike for my 8 mile ride to work.  I already had a nice road bike and a serviceable mountain bike, but I wanted a bike that could handle the weather, hills, and night conditions in the area.  Because I was planning to ride the bike frequently, I set a high budget for what I was willing to spend.

     At every other bike shop I went to, I found that the sales people were focused on selling me something as close as possible to the upper end of my budget.  I didn't mind that approach necessarily, since I was open about my budget, but it was clear their sales algorithm was designed to maximize profit.
     I had a very different experience when I met Mason at Edge & Spoke.  He spent about 30 minutes interviewing me about the specifics of my needs, asking thoughtful questions about the details of my commute, and the specifics of which route I was taking to work.  He then made a point of DOWNSELLING me to a bike that was about 2/3 of the cost I what I was willing to spend, but he thought was a better fit for what I needed.
     He then spent about an hour fitting me on the bike.  It was the most thorough fitting I've ever had on a bike, and included swapping out some parts to make the bike a better fit.
     A year later, I can say that Mason's advice was correct- I love the bike he recommended, and it's added greatly to me enjoying my bike commute.  I also appreciate that he placed my needs ahead of just making a sale.  The next time I needed to make a bike purchase, they had earned my loyalty, and I made a point of only shopping with the Edge & Spoke team.

     As a small business owner, the lesson that was emphasized to me was that the best way to make a sale is emphasizing the need of the client.  By placing the needs of the client first, you build brand loyalty.

2. Know what you are- don't try to be too much.   

     I enjoy watching cooking shows.  On shows like "Restaurant Impossible," one of the key points that they make is that it's a mistake to have too large of a menu.  Rather, have a smaller menu you know well, and make sure everything you sell is great.
     At Edge & Spoke, they primarily sell Specialized brand bikes.  At first I was surprised that they didn't sell 20 different types of bicycles.  However, when the Edge & Spoke team shared their logic, it made sense to me.  The strength of the shop is that they are a small, intimate shop that provides the best service.  By limiting their scope to fewer manufacturers, that allows them to be great at everything they sell.  Specialized is a great company with a diverse line that meets nearly every cycling need, so they wouldn't gain much by having the comparable bikes from other manufacturers like Cannondale and Trek- it would really lead to duplication of inventory.
     By staying focused, it allows the team to be experts on all things Specialized.  I've been in the store several times when the team has been talking to a customer, and they were able to give very specific details about the Specialized supply chain, things like "they over-ordered on the 2013 model, so on March 3 that model should be available at discount."  By narrowing the market, the Edge & Spoke team is able to provide better service and value on what they do sell.

     This made me realize that as a small business owner, we need to make sure everything we do is great.  At Lake Washington Sports & Spine, we try to stay true to our vision to "Keep People Active" using our expertise in sports medicine and being great in our use of musculoskeletal ultrasound and exercise prescription.  That also means that we can't be great at everything, and recognize that if we can't be great, we are better off referring clients looking for something else elsewhere.

3. Sweat the small details.
     I remember when I purchased my first bike at Edge & Spoke, Venny offered me a free branded water bottle.  I told him I didn't need one, since I had plenty at home, and then Venny told me about the thought and product testing they did to find the best water bottle on the market.  So I took one, and he was right- it's a great water bottle.  

     This is a small detail, but it also gives insight into the way Venny thinks.  Many places blow off details like which vendor they should use for their water bottle, but this is clearly something he put thought into.  Also, he was excited to share the product to make me happy- by giving me a free water bottle, he made was not making any money.  He was simply trying to make me a happier customer.
     The take home as a small business owner- when you show your customers that you are rooting for their happiness, you build loyalty.

4. Engaging customers as partners.
     Part of Edge & Spoke's commitment to their clients is 1 year of maintenance.  This is beyond the industry standard, and I can personally validate this is something they stand behind.
     Since I ride my commuter frequently, I've had to bring it in for small adjustments three times (which is to be expected).  Every time I brought in the bike, the team has welcomed me and always started by asking me if I am enjoying the bike.  That struck me as such a positive way to view the encounter- they could have viewed me coming in as unpaid labor, but they prioritized my happiness over their labor.
     One of the repairs they did is something that I think that Edge & Spoke could have considered "user error" on my end- I bent the front derailleur while shifting too aggressively.  One of the mechanics, Jack, looked at it, and asked Venny to help him out since it was a more complicated repair.   I think that Edge & Spoke was within their rights to charge me for the repair since it was my fault.  Instead, Venny repaired it, and promised that if his repair didn't work, he'd swap it out for free.
      His repair worked great, and I've ridden hundreds of miles on the repair without a problem.  That said, Venny built up a ton of loyalty from me by engaging me as a partner and treating me in a reasonable manner.
      As a small business owner, that is the biggest take home for me.  Venny treats me as a partner, and has made it clear to me over multiple encounters in the past year that he wants me to love my cycling experience.   Similarly, as a physician, my number one priority is that I want my patients to stay active and love what they are doing.

Lake Washington Sports & Spine wants to congratulate Edge & Spoke on their rebranding, and thank them for helping Keep People Active!