Trip Goolsby, MD, is the physician. He ran a community oncology practice in a small Louisiana town. Excellent medicine — and patients who had somewhere else to go.

He wasn't losing ground because the hospital had better oncologists. He was losing ground because four forces were pushing in the same direction at once, and not one of them had anything to do with how he practiced medicine: reimbursement changes that cut what oncology actually paid; out-migration steadily shrinking the town he practiced in; three competing hospital systems pulling patients he'd otherwise have seen; and policy shifts, local and national, that made an independent community oncology practice harder to sustain every year it stayed independent.

Read that list again, because it's probably a version of your list. Every one of those forces is external. You cannot negotiate with any of them. You can't call the payer and ask for 2012 back, you can't repopulate a town, you can't make the hospital across the street disappear, and you certainly can't fix the policy environment from an exam room.

So in 2013 I changed what the practice was. Community oncology became integrative, regenerative, and age-reversal medicine — a model built on what people in that region would actually pay for, delivered by a physician who was already excellent. Trip did the medicine. I rebuilt the business around it.

That practice is now Infinite Health — multiple locations. Gross income has grown about 20% a year since.

Your version of this probably isn't that dramatic. Most aren't. Most are practices doing perfectly well on paper, where the money somehow doesn't reach the owner. But the answer is the same in both cases, and it's the thing nobody tells you in medical school: when you can't change the forces acting on the practice, you change what the practice sells and how it runs.

The first thing I changed wasn't the medicine, and it wasn't the marketing. It was what the practice sold.

We were selling visits. A visit is a one-off — it happens, and then everyone waits to find out whether that patient ever comes back. So I changed the unit. Instead of booking appointments one at a time, we enrolled patients in a membership: an ongoing program with a defined path through it. That single change rewrote the intake conversation, the schedule, and the question of who was responsible for a patient between visits — which, before that, was nobody.

But a program nobody follows is just a thing people quit. So the other half of the change was a patient compliance protocol — an actual system for whether people were doing what they'd signed up to do. Who follows up, when, and what happens when somebody quietly stops showing up. Before, compliance was whatever each patient's own discipline happened to produce. After, it was a named person's job.

Those were never two changes. They were one. The membership defined what a patient was actually enrolled in; the compliance protocol is what made sure it happened. And patients who follow the protocol get better results — which is the entire reason Trip does this work in the first place.