Welcome to the Evolution of Medicine podcast! In this episode, James continues the Group Visit Series with Swathi Rao, PA-C, who owns and operates a functional medicine practice in Indianapolis, IN. What makes her practice unique is the focus on the power of community in conjunction with group visits to inspire lasting lifestyle change in her patients. In addition to running successful group visits in her practice, Swathi has tapped into the local community, like restaurants and yoga studios, to build new business and maintain the health of the patients she’s seeing in-clinic. It’s an interesting avenue of the group visit model that we haven’t yet explored on the Group Visit Series, and I think it will really impact your perspective on group visits and how they can become integral to the communities they service. Highlights of this episode include:

  • Swathi’s journey to functional medicine and to discovering the power of group visits
  • How she separates group events for patients and group medical visits when billing insurance
  • How she leverages the value of the group visit community structure for the benefit of both her community and her patient base
  • How Swathi maximizes peer-to-peer interaction in her group visits
  • Her tried-and-true strategies for recruiting patients to group visits
  • Why some of her best referrals aren’t coming from the usual sources
  • Her profound advice for practitioners who are still on the fence about group visits
  • And so much more!

Resources mentioned in this episode:
goevomed.com/accelerator
functionalforum.com
bewellfamilycare.com

Podcast by Swathi Rao

James Maskell: Hello and welcome to the podcast. We continue our group visit series with Swathi Rao. She is a physician’s assistant in Indianapolis with her own practice. And one of the things that we learnt here is how she’s been using the power of community and group visits in her practice.

What you’ll hear today is that as well as using groups to actually attract people from the local community into the practice through restaurants and yoga studios and many of the things that we’ve spoken about before for building new business, she’s actually using groups to maintain the health of the population of people who’ve been through the one-on-one care. And I really think this is an interesting part of the model, something we haven’t discussed on the series, so enjoy.

So, a warm welcome to the podcast, Dr. Swathi Rao, welcome, Doc.

Swathi Rao: Hey James, it’s so great to be with you.

James Maskell: It’s awesome to have you hear on this group visit series and I’m really excited to share with our audience some of what you’ve learnt and somehow it can really be a part of the modern functional medicine practice. So why don’t we just start right at the beginning? Why don’t you just share with our audience a little bit about your journey to become a functional medicine doctor and then your journey to discover group visits?

Swathi Rao: Yeah, actually my journey started out like a lot of providers I think, where we were doing family practice, doing it pretty well, but felt like over and over I was telling patients the same thing, “That fatigue that you have, the brain loss that you have, that’s just part of getting older, that’s just a part of having two kids at home.” And I felt like one day I just stepped back and thought, “This can’t possibly be right, there’s got to be more to it than that.”

And serendipity, as we were talking about, actually made me leave a traditional family practice setting and I actually ended up doing physicals on firefighters, policemen, FBI agents and all of their bloodwork for those visits was actually government granted. So we were getting these amazing labs that would show us inflammation and markers of cholesterol, but my prescription pad was taken away from me, because I was not their primary care provider. And so we thought, “What do I do in order to get these guys well?” And what was really fun was when we would do these physicals we’d actually go onsite to the firehouses and do physicals on all of them. And so they would invite us to eat with them and they would invite us to hang out with them. We would hang out for the weekend and it was amazing when you saw the correlation between how they ate, how they stressed, how they moved and their labs.

And so that’s kind of how this whole thing started. And then once we got back into family practice, it was just a hard niche to get away. So we started doing more functional medicine and now we’re fully integrated for really the last 10 years. And then the group visits really started by getting people together in waiting rooms and learning how to cook and learning how to do yoga, because it was so powerful when you could get that community done. And now we’re doing teaching kitchens and we’re doing so much more.

James Maskell: Amazing. Yeah, look I love to hear all the different ways that groups have been brought together. Can you share the difference, in your mind, between group events for patients and group medical visits and what the difference is in your mind and how you like to separate it?

Swathi Rao: Yeah, so that’s a great question. Initially when we started we did everything under insurance billing, which is what I would really declare as a group visit. And what we found was that it wasn’t really hitting all of the patients that we wanted to serve and there were certain types of visits that we would do that were more difficult to put under an insurance billing platform. So now we really call them our group visits and sometimes we submit them to insurance, sometimes we don’t.

So we have a motto in our office, it’s, you have to eat well, sleep well, move well and poop well in order to be well. And so our group visits or our shared visits are really doused down into one of those categories. So eat well, we have all of our food prep classes and that type of thing. Move well, sometimes we’ll do walking visits with people, sometimes we’ll do things where we have yoga or we actually had a karate instructor come in, just to give people a different perspective of what they can do to exercise better.

So for me they all fall into the same category. When I talk about an actual group visit, that’s one where we actually bill to insurance. We do a level three office visit where we do a quick exam on them, as well as we do something very didactic. The group visits are a bit more structured. So for example, when we’re doing our lunchtime summer fun classes for our kids, they’re a little bit less structured. And so those we just sort of do as a pay-as-you-go type of a class.

James Maskell: Okay, got it. So obviously in the previous podcasts episodes we’ve heard from the Cleveland Clinic, we’ve heard from other doctors who’ve been doing it in all kinds of different settings, private practice, in a university hospital, in a bigger group. What has been the primary way that you’ve found to use the value of this community structure for the benefit of your community and your patient base?

Swathi Rao: So I think the question was asked, what was the big value? What I love about our visits is, typically the structure of our group visits is patients come in and we do a didactic portion where they learn about turmeric and how to cook with that and why is it important for inflammation. And then we have a hands-on component where we’re actually cooking or actually doing some kind of a movement type of a visit. And my favorite part is after that’s done, I tend to back away and allow patients to converse with one another. That’s the part that I think is the most profound portion, because that’s where you take the provider out of it and you start having self-education and you start learning about, “How do I make these things that are goals of mine plausible in my life? And how do I learn from my peers? How do I learn from my community? And then how do I build on that community?” So it’s the end of the group visit where they talk to one another, that’s the best part of the visit for me and I think that’s where the value is.

James Maskell: Yeah, what have you done in the groups to be able to maximize that peer-to-peer interaction?

Swathi Rao: Honestly, for me, I feel like what we do is all throughout the class we’re really giving them the opportunity to say a few things here and there. But for me in the teaching kitchen, putting food in front of people and utilizing that food as fellowship and especially when it’s like-minded food, this is all gluten-free, everyone in this class is this way, this is part of an elimination diet or Whole30 or whatever it is that we choose, the conversation is just so dynamic and it happens very organically. And that’s so powerful, to let them say, “Hey, you know what? I do that a lot. I go into a 10-minute meeting and boy I get really hungry and when those bagels are sitting there, hey, this is what I do when that happens.” And it’s such a great powerful tool that they can educate one another.

James Maskell: Yeah there’s so many lessons in being healthy that aren’t, they don’t come from a textbook, right? It’s real life experience. One of the things that I’ve noticed is just how after a while people start to realize they’re almost like an unpaid health coach for each other. They’re not saying things that are disruptive, they’re not saying things that are contrarian, they’re saying things that they know will help other people. Have you found that in the journey and are there ways to encourage people to play that kind of role?

Swathi Rao: Absolutely, and I think one of the first things that they notice is, “Hey, I’m not the only one that’s like this. I’m not the only one that falls apart and cheats and then feels guilty about it. I’m not the only one that has to avoid gluten in order to stay healthy.” And I think it’s an instant relief for them that they know that there are other people that are that way. I think fellowship is powerful and I think community is powerful. And when you can establish that for them, that is huge in the outcome of what happens with them. And then all the little tidbits that they share with one another, that’s just the same way that we have in every day of our lives.

When you’re in a journey with someone else, it feels like much less of a hasty journey, right? It feels much less troublesome, burdensome. All of the sudden it feels like something that is doable.

James Maskell: Yeah, so just, you say that, one of the things I was thinking about with you having run this practice for so long, is that you have some people that did the elimination diet and got better 10 years ago and you have some people that are doing the elimination diet and getting better today and one of the things that I’ve noticed through my journey is that a lot of times behavior change is much better facilitated by a peer who’s just further down the journey. So do you consciously try and bring the veterans and the newbies together?

Swathi Rao: We don’t, because it’s kind of first-come, first-served, but it almost always works out that way. And I think the veterans look back and go, “Man, I remember when I was that way. I’ve really come a long way. Every now and then when I eat something I’m not supposed to, it’s okay.” And they speak up and they start saying, “Hey, I’ve been there before, I know how hard this is, but give it another couple of weeks, it’ll get easy and pretty soon those things won’t even look like something that you want anymore.” And that’s also where I love having the health coaches or local restaurateurs come in, is because they learn about what these people are wanting, they learn what the demand is out there so that they can go back and make changes on their own menus and say, “You know what? We can make a variation on this dish, come on by and we’ll cook you something that’s gluten- and dairy-free and I can make it taste good.” I mean how powerful is that for someone to do that?

James Maskell: Yeah, tell us a little bit more about that, interacting with the local restaurants, because ultimately we’ve advocated in our Practice Accelerator and on the Functional Forum for building relationships in the community with like-minded businesses and obviously healthy restaurants and restaurants that have the ability to do that kind of thing, chains don’t really have as much ability to do it. So how did you start that process and how much easier did it make it to actually do something with them rather than just say, “Hey, can you send your patients here?”

Swathi Rao: Yeah, so it was really fun. A lot of it started out with patients that were owners of local restaurants. So it started out really easily and then as we started doing more and more…So we have what we call community partners in our office. So we actually are community partnered with some of the local yoga clubs that are here. We have community partners that offer some of our concierge patients discounted rates or you can get a free gluten-free muffin when you stop by the gluten-free bakery. You know what I mean, if you’re a patient here. So those are great ways for us to start to get touchpoints with the companies that we really love and with the types of foods that we want patients to eat.

I think when you’ve been eating this way for five to 10 years, it’s really hard to cook at home all the time and you want to go out and get something to eat every now and then. And as we go it’s really been more word of mouth that’s been having people come up and say, “Hey, I’d love to do one of these group visits with you. What do you think?” And so we love it. We feel like thus far we’ve had more than our handful of folks that have come in that have really enjoyed cooking with us. And it’s so fun, right? For many anyways, after eating healthy for as long as I have, it’s so fun to see, like we were talking about reaching out to the folks that we know at the Moroccan restaurant, how fun is that to have them come in and do a really fun series with us?

James Maskell: Yeah, that’s great. So what’s been the most popular restaurants with your patients and what have been the best referral relationships for you from outside of the clinic?

Swathi Rao: Probably our best ones have been the gluten-free and the allergen-free bakeries that are in Indianapolis. Indianapolis is very forward-thinking when it comes to this. All of our chocolate classes fill up just like that, right? You say chocolate and healthy and everyone’s here. The bakeries have been probably our best referral sources and we have connections with almost all of them for our patients.

And I was actually thinking back, James, when you said, what are we doing in order to really establish that fellowship? And I had just said something I had forgotten about. A lot of our group visits are done in series. And so instead of just doing a class here or a class there, we’re trying to offer some classes, whether it be about detox or healthy weight or those types of things, in a series of four to six classes. So patients are coming and meeting each other over and over again, over a four to six-week period of time and I think that that also really results in a strong community that gets formed.

James Maskell: Yeah, how do you structure that? Do people commit to a certain number of weeks?

Swathi Rao: Yeah, and so essentially what we do is they either pay per class or we give them a discounted rate if they pay for the whole series. And what we’ve found is a lot of times people do the whole series. Our healthy weight loss class, we actually do the series and you have to commit to the whole think. And so we do BIAs at the beginning, BIAs at the end, we do vital signs at every visit and we really talk about all the different facets of weight.

So weight and the microbiome, weight and detoxification, weight and so it’s not always just about what to eat. Weight and stress, weight and hormones. And so they’re really learning so much about a topic that they’re very passionate about.

James Maskell: Yeah, I mean ultimately the kind of patient that wants to come to a functional medicine doctor for weight is someone who’s already been, probably, through the change-my-eating plan. And then there’s a real underlying cause that they haven’t been able to get to. That sounds really smart.

What about recruiting, because I know a lot of practitioners who, one of the things that they come up against is getting bums on seats basically, to get people to commit to it and getting people to want to do it. What are the things you’ve learnt along the way as far as doing that? Because I know that a lot of practitioners have maybe tried it once and didn’t get the uptake that they were hoping for and then leave it. But it sounds like you’ve been able to do that pretty successfully.

Swathi Rao: You know, we hit it on the nose sometimes and sometimes we still have classes that we can’t quite fill. And so I think the biggest thing for me was, and it took me almost a year to figure this out, is you have to reach outside of your patient base, especially if you have a concierge practice, in order to be able to do this. And so really marketing and having those community partners that will then advertise these classes for you has been a huge deal.

So everyone that goes into the gluten-free bakery is going to see a class potentially, or hopefully, a flyer that says, “Hey, come and learn how you can do more, better, gluten-free.” What a fantastic way to not only increase access to our own office, but then also to those classes. And I think almost every practitioner will tell you, there’s only a subset of patients that you can see because your time is limited. But boy, these visits you can reach so much more than who is even in your patient base. And that’s really rewarding.

And so we actually try to put out flyers and do a lot of marketing at the library, at the local gyms, at the yoga places, people that would be really interested. And then once you start to get going, it’s all about word of mouth.

The first couple of classes I would recommend if someone’s having trouble filling seats, what we’ve told them is, if we haven’t been able to fill the group visit class, we’ve called the people that have signed up and said, “Hey, you know what? Bring a friend and we’ll just allow you to have that friend here for free.” And that friend is typically someone that then goes out and tells three other people. And then all of a sudden, you don’t have spaces for your classes.

James Maskell: Yeah, that’s amazing. So what does a typical week in your practice look like now in terms of the group visits? When have you found during the week is the best time to do them?

Swathi Rao: All over the place. So I think it’s about as individual as your functional medicine plans go, is there’s going to be the people that want evening classes, there’s going to be people that want the morning classes. So we’ve really found that allowing our patients to have a variety to choose from in a schedule is going to give them the best opportunity to get the most amount of people into our kitchen.

And so we do some classes…Kids we’re finding more in the summertime and during the day is a fantastic spot for kids. And our kid’s series we typically do in series as well. And we really do … And then we’ve also realized, to give them variety as far as how much prep work they’re doing on their own, we had some classes where folks will come in and actually cook a dinner for four and take it home. And we have some classes where now they’re just coming in and watching someone actually do more of a presentation. So again, we’re finding everyone wants to do different things and if you can give them a real variety, that’s just a great way to get more participation.

James Maskell: Got it. I’m just reflecting on the way that you’ve set things up and obviously at the Cleveland Clinic, they kind of dangle the doctor as the carrot that people can get to if they come through the series. And so people go into the group visit because they think, “Okay, maybe I’ll get to see Mark Hyman on the other end of it.” And then loads of people get better and don’t need to see the doctor. And so it’s kind of like a, that structure. It seems like you do a little bit of that with the marketing of these group visits out, but you’re also doing it the other way where it’s like, “Hey, come in, see the doctor, get your customized plan and then let’s use the groups ongoing to maintain health and continue community once people are better.” Are you doing both simultaneously or have you found one works better than the other?

Swathi Rao: You’re exactly right. I still find that when we’re in a group it’s very difficult for me to get individualized and as individualized as I want to be. Having said that, I find during my individual visits there are certain things that I say over and over and over again. And that’s where we really use those group settings, to really give those broad strokes and the broad vision of what we want.

Let’s talk about thyroid health, for example, we’re doing a class on thyroid. How do you eat better? How do you stress better to have your thyroid be optimized? I might do a didactic portion on thyroid biochemistry just so they understand that, but I find that for something like that, an individualized office visit is going to be much better for me. So I think that that’s exactly what we do, is we’re doing…The primary crux of our practice is still individual, one-on-one based medicine, but then we’re using the group visits as our tools, like you said, to really keep them healthy, to optimize health, to get them more information than what we can even give them in those longer office visit slots that they have. That’s what works best for me.

James Maskell: Yeah, that’s really great. Do you find that people then get re-energized and want to come back in and do more one-on-one visits or do they just stick as part of the group and find that to be enough care? I guess one of the things I always think about is, what’s enough care for a normal person? Does a normal person need a functional medicine doctor? Someone who’s not ill, it seems like we’re over-utilizing resources if we’re putting those people on gut microbiome tests. Obviously if you have a chronic illness that you’re trying to reverse, it makes a lot of sense.

So if you had to redesign, based on your own experience, the primary care of the future, how would you organize the resources amongst primary care, functional medicine and group visits to optimize the health of a wider community?

Swathi Rao: I think that’s just it, is what you said is, not ill does not mean that you are actually well. And I think we know that in the functional medicine community, right? So for me, knowledge and education of how you learn your risk factors for inflammation, for lack of methylation so that you can prevent yourself from getting sick, is the ultimate goal for the entire population. How do you do that though in individual one-on-one visits? You can’t.

So I think what you have to do is you have to utilize group visit type classes to really distribute knowledge. What does it mean to have a cardio CRP checked? What does it mean to have these functional markers checked? And then really encourage them to go and ask and demand that these tests are done on a routine basis so that we can really prevent illness. That’s the goal right? If we waited for every single person to get ill before they came in, we’re really still missing the boat on functional medicine. That’s the reason why we focused so much on educating kids, educating college kids, because this is how it should be.

I think the conversation in the grocery line shouldn’t be, “Are you diabetic? Now what meds are you taking for your blood pressure?” I think the conversation should be, “Hey, my cardio CRP came back and I’m looking fantastic. My insulin levels are back and my provider tells me that I’m perfect.” And so how do we get that into a setting where it’s easily accessible? That’s a challenge and I think group visits area great way to facilitate knowledge and facilitate conversation.

James Maskell: Absolutely. So what advice would you have for doctors who are sort of dipping their toe in the water, interested in in it, like the concept but haven’t quite got there yet?

Swathi Rao: I would tell them that it’s the best thing that I’ve ever done. We were at the conference together, James, not too long ago and I thought it was really interesting that they were talking about the Cleveland Clinic trial, where they were talking about the patient that went and saw the empathetic provider with a common cold and they actually got better from the common cold two days faster. And the patient that actually saw a not very empathetic, short, cold practitioner and they actually had two days longer to get rid of the common cold, right? And then vice-versa, they talked about practitioner’s wellness and wellbeing. I think when every day you can go home and you know that you’re making a change in someone’s lives and you’re helping them not get sick, I think that that actually fares for a very happy practitioner.

So I would tell anyone to do this. Learn more about it. Figure out their own niche, because I think that that’s, you have to figure out what your community needs, what your patients need and then really offer that for them. And I think that there is no cookie cutter model. And my gut instinct for that is, couple pieces of advice I would give, one, give them a variety. Make sure that they have several different options that they can choose from so they know what kind of functional medicine that they can have. And then two, even when you’re doing group visits, this was a mistake I made, you don’t always have to be there as the practitioner, that your nurses can run those. You can utilize local health coaches to run those. You need to help plan them so that they speak to the practice and to the vision of the practice, but you don’t always have to be there, because your time is very limited.

James Maskell: Yeah, no I think that’s dead on. Yeah no, there’s a lot with empathy. One of the practitioners that I interviewed about this recently referred to a group visit as having 15 unpaid health coaches on your team when you start in the group. Have you found differences in outcomes where one group is, you said that weight loss group, that’s going through it, as compared to just a drop-in person?

Swathi Rao: Oh, hands down. I think there’s a Weight Watchers effect, that’s what I always call it, is you’re actually responsible and you have a lot of ownership when you have to come back in and share what’s happening with you at that next visit, next week when you come in. And so I think that there is…I think when you do anything as a group, one, you’re not alone. You’re so much more motivated. Two, you literally are going to go back in and report to this group that’s holding you accountable for what’s happening. And three, I really do think that it becomes a realistic possibility.

I have so many patients that come in sometimes that just feel overwhelmed. They know what they have to do, they’ve heard me say it for years, but they just don’t feel like they can do it. And all of the sudden you put them into a mix with other people, their own peers, not just me, and this is something that becomes not only realistic and possible, but it becomes fun. And then they’re coming in going, “Hey guys, I had this awesome recipe.”

And some of our classes we’ve actually even allowed our patients to stay connected via Facebook, under our Facebook group because they’ve wanted to keep in touch. And so yeah, I think it’s powerful, the sense of community and the sense of group.

James Maskell: and what do you see for the future? Who do you see doing these visits? Do you see them, growing them, or are you just happy with the structure that you have right now and just going to keep running the practice like it is?

Swathi Rao: No I would like to really keep growing them and keep growing them. I’d really love to see a time and place when we’re offering a group visit model at least even once a week in our clinic, but I think that the hospitals taking this up is phenomenal. I’d really like to see it become a much bigger and a much more of a community oriented type of a meeting space.

Somehow or another I feel like we need to bring in the food industry, the health industry and medicine together, so that we’re working as a team to help make patient’s health better instead of working against one another.

James Maskell: Beautiful. Yeah that makes a lot of sense. Well look, we look forward to following the progress of clinic and thanks so much for sharing so much great information and I hope that…One of the things that this really brought me is just clarifying my thinking on what should we…I’ve been very focused, I would say, over the last five years, on new patient acquisition, because that’s what we’re talking about in the Practice Accelerator and that’s what a lot of practitioners struggle with, especially when they move to a cash model. But ultimately it’s not all about acquisition, it’s about ongoing community support for people once they’re better. Because if they go straight back into an isolated environment, do the behavior changes last?

And so I really appreciate you…It takes something to be on the front lines and just working it out with the need as you go, rather than just following from other people. So thank you for the leadership and thank you for the support and thank you for agreeing to be on the podcast.

Swathi Rao: Yeah, thank you so much for doing this. This is such a cool way to really get us as practitioners more knowledge and we appreciate you so much.

James Maskell: Awesome. This has been Dr. Swathi Rao. If you want to find out more about her practice you can find it online. What’s the best website?

Swathi Rao: Yup, so I’m a PA actually and I own my own practice, so just Swathi. And the website is, it’s bewellfamilycare.com. B-E-W-E-L-L-familycare.com. I think we’ve got some recipes on there and also you’ll be able to see some of the things that we’re doing for our Kids Can Cook summer series, as well as our summer group visits. We actually have two series that are on there right now, so if anyone’s interested in what types of classes we’re offering, that’s a great place to visit.

James Maskell: Beautiful. Well we look forward to following that and it’s great to actually see other people’s websites and see how they’re selling it and see how they’re getting other people into these groups. So make sure to check out the website. Thanks so much for being part of the Evolution of Medicine Podcast. We’ve been with Swathi Rao, a PA working in Indiana and building a functional medicine practice and running it for the last 10 years.

I’m your host James Maskell and we’ll see you next time.

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