Good morning Dr. Harvey, how are you doing?
Good morning Dr. Maltzberg, I'm doing well, thanks. How are you doing?
I have to admit I'm a little disappointed. I got used to one time you wore a helmet, one time you had a sign in your head that said who or what. Sometimes you throw some international signs for a loser at me. Today it's just you.
Yeah, yeah, just me. Well, just me and I got my McDonald's coffee here. But yeah, you know, a lot of times I do like that one show where I put a sticky note on my forehead and couldn't think of a good sticky note for this one. But I will be doing that more in the future, though. I think it's helpful to put sticky notes on your forehead.
It's very helpful.
It's very helpful. I think... We've been hoping for McDonald's to reach out to us for our sponsorship for their decapped coffee. Unfortunately, we don't have the connects right now.
Exactly. I know. If they keep on not sponsoring us, we might have to stop mentioning McDonald's. And this delicious decapped coffee. I'm going to drink some right now. Yum, yum. Awesome. Maybe that'll do it. I don't know.
So I guess our focus is on TMS and you should probably get back to it. So what's our topic today?
Yeah, so our topic today, and I can't believe we didn't do this topic sooner because this is kind of the no-brainer topic. And that's the topic of which brand of TMS machine should you buy? If you're going to go into practice, if you want to do TMS, there are 12 brands of TMS machines out there. And when people are thinking about doing a TMS practice, the one question they ask is, which brand should I get?
So it just kind of surprises me that we haven't talked about that yet.
Yeah. And it's a great question because it's like, oh, I want to get a TMS machine. And then it's not as simple as all TMS is created equal. So it is an important question.
Right, it is, it is, yeah, yeah. And it occurred to me that, you know, I mean, I'm not sure what the title of this podcast is going to be, but we might call it, you know, which brand should you buy or something like that. So it kind of amused me to picture the salespeople from these 12 companies and they're going to see that title and go, oh my gosh, what did Harvey say?
Yeah. What did Maltzburg say? Oh, no. Are they going to trash us?
We're prepared to sell out. No, not really. I think we both care about getting unbiased information, just for the listener.
We do. Yeah, we actually are. We are trying to be unbiased, but yeah.
My other podcast... A pharmaceutical company reached out and they were just like, hey, do you want some resources on ADHD? And I was like, I will never work with a pharmaceutical company. And then they were like, no, I was just trying to help. I was like, oh, I'm an idiot.
Yeah, yeah, yeah. It's kind of similar with this. But yeah, so I think, you know, we don't want the TMS manufacturers to be like calling their lawyers and stuff like that. Because, you know, if I said everything I really think, I probably would offend a couple of companies. Yeah. But, you know, what we're going to do, and I think this will work, what we're going to do is we, even though there are 12 brands and machines out there, we are going to not mention a single brand name.
We're not going to mention the brands. We're going to talk about what you should look for in different companies, what questions you should ask, and how to best make a decision for the good of your practice. But we're going to be very careful to not name names.
Yeah, I think that's a good idea. And, you know, if you're thinking about TMS, I think you should do it, be thoughtful and do the research and, you know, not, if you can't think through the problem, you probably shouldn't be getting a TMS machine. So I think that's a really good plan of just kind of just going through the different variables and seeing where things land.
Absolutely. Absolutely. And it's an important decision. You know, it's like, uh, It's the machine you're going to be stuck with for years and it's almost like having a business relationship with that company because you're going to be giving that company a bunch of your money and in return you're going to expect that company to provide you with a machine that works with a machine that can do what you want it to do and it's not going to break down and all those.
There's a lot of things to take into account.
Yeah. I can't twist your arm at the end and have you name a company at the end?
Yeah. After the microphone's off, I will name names.
I'm going to keep recording, folks. I'm going to hot mic, Dr. Harvey.
Yeah. Oh, I think you already know who I'm talking about here.
All right. So let's go through now. How many different things are you thinking about when you're thinking about picking the TMS brain?
Well, yeah. So when you consider which TMS machine you should buy, there are exactly nine things you should know. According to science, there are nine things you should know. 00. No more, no less. No more, no less. Yeah. These are the exact things you should ask yourself. And I got the list right here. And for you, my audience, I will share my wisdom with you.
Spectacular. Let's get started.
All right. All right. Okay. So let's get this started. And what we're going to do here is I'm going to, you know, the one that's the most important one, I'm going to save that one for last. That way you're forced to listen to the whole podcast.
You're forced to listen to us. That's right.
Tricky, tricky. So, yeah, so I'm going to say the most important one for last, and I'm going to start with the obvious one. So the obvious one, the obvious one is, I mean, this one you guys have already figured out, is how much does the device cost? You know, what is the upfront cost? What's the rental price? What's the rental fee cost? That's the obvious one. And that can vary quite a bit.
And it's often, depending on if it's a rental or a purchase, if it's a purchase, it's going to be in the many tens of thousands range. But it's a big cost. And we're not brain surgeons here. We're psychiatrists. So tens of thousands of dollars is a lot. I mean, it's a lot of money for anybody, but it's certainly a lot of money for us.
Yeah, and the costs are different. I also know there's different fee structures in terms of monthly fees, buying the machine. Yeah.
Yeah. So it can be hard to make an apples to apples comparison because some might have, you know, a low upfront cost and then a rental fee or it's only a rental fee or it's only a purchase. So that varies. But yeah, that's the first thing to take into account. That's number one.
Yeah.
Number two, number two is other costs of the machine. And for this one, you know, one thing I have in mind is that sometimes there's a per use fee where there's a fee for every treatment where the number of treatments you do is tracked and there's a fee for every treatment. So, you know, if you have a high volume practice, you need to ask yourself how much money is that going to be?
You know, that could be A bigger cost than the cost of the machine itself. So you need to think about the ongoing costs, including the per-use fee, and also sort of a smaller cost is there are sometimes consumables that you need for the treatments. You know, sometimes they sell these little caps that you use for Navigate, you know, these little Headcaps with the markings on it for navigation.
So those cost money and there might be other consumable things. And the cost of those, you know, sometimes it's pretty minor, but sometimes it can be relatively large. So that's another thing that you need to take into account when you compare the cost of the different machines.
Yeah, you bring up a great point. And matching, you know, as you mentioned, you need to match it to the way that you're trying to practice. If you have a practice that you want to do TMS just a little bit, which we didn't recommend, but you should be thinking about the pricing differently than if you're planning on doing a ton of treatments, in which case the per treatment cost is going to matter more.
And then when you say consumables, you have to, you know, add that to the per treatment. Treatment Cost of things When you're factoring things in
Exactly, right. And the fancy business people, they talk about PPUs, price per unit. And so like when I had a, in a previous practice, I had a machine of a brand that I, I will not be naming the brand, but it was purely a rental fee every year, no per use fee. So for that, if I I treated one patient a year then the cost was gigantic but the more patients I treated the lower the cost per patient so that's that's that's something that's you know so the PPU goes down with higher volume but again it depends on your depends on your financial model so yeah all right what's our number three number three is replacements replacement parts Sometimes the coil wears out.
The coil can wear out and you need to know, do they replace that coil for free or does it cost a business? Zillion Dollars, you know, and I think sometimes that can be a hidden fee where, you know, they don't really tell you much about that. And then, you know, three or four years later, you need a new coil. And it's like, surprise, the cost of that new coil is gigantic.
So, so you know, you know, how long do those coils last? How many treatments can they do before they need to be replaced? And if you do have to replace it, how much does that cost? Other parts too, but, but I'm mostly talking oil itself. So number four is service. And I'm mostly talking about if, you know, no matter which brand you get, occasionally there's going to be a glitch, you know, like maybe there's a software glitch and it won't turn on right or the coil wears out when you didn't expect it to or something.
There's all sorts of things that could happen. And when those things happen, How does the company respond to that? Do they, you know, do they say get right on the phone with you and fix the problem immediately? Or do they say, well, you know, we'll have someone come by in a couple of weeks, you know, and if you have someone coming in for, you have a bunch of patients coming in for treatment every day, And if there's, if it's going to take a few days to take care of the problem with the machine, then that's a really, really bad situation because you don't want to make patients wait.
You don't want to interrupt a bunch of patients' treatments. So you need prompt service. You need to take care of it promptly. So that's number four. Number five. Number five is portability. And I think portability is something that is one of the far less obvious ones. But some of the machines are quite portable. You can just pack them up and bring them to another location yourself pretty easily with no problem and no drama.
And other machines are much less portable. They might be these things with a special chair and a very large machine and a machine that you have to have a special Dr. Justin Marchegiani Inappropriately expensive also so you need to you need to ask those questions you know and if it's a machine you can't move yourself you need to find out how much is it going to move if I move to it because you know if you use that machine for 10 years 15 years and you might you know your your lease is going to run out you're going to want to move to another building you're going to want to move to another floor of the same building it could be much more complicated than you anticipated just to move the machine so affordability Awesome.
Okay. Number six. Number six is you got to ask yourself, what does the exit look like? Like if I decide to stop doing TMS, like let's say they invent something better and I suddenly want to stop doing TMS or, you know, if you get another position at another company and you want to stop your TMS practice, you want to ask yourself, what does the exit look like?
Am I stuck with this machine? Can I sell it? Can I not sell it? And one thing that surprises some people is that sometimes there's sort of a software lock on the machine, right? That's really the best way I can explain it. So that if you transfer it to another practice or another person, there could be a fee associated with that. You can't just sell it to somebody else and everything's fine.
You might have to give more money to the company just to transfer that machine to another person. So you've got to check that. You've got to check and see if I stop wanting to use this machine, is this going to become a super expensive coat hanger that I'm stuck with for life? Or can I sell it? Is it easy to get rid of or is it hard to get rid of?
Is it cheap to get rid of or is it expensive to get rid of? And you've got to ask those questions. Yeah. All right. Number seven. You should wonder about the coolant system. You should wonder about thermal management. If you run a machine a whole bunch, sometimes it'll overheat and shut down, and you have to wait a while before your next treatment. And if you have a high-volume practice, and I encourage you to treat a lot of patients instead of a small number of patients, if you have a high-volume practice, that can become important.
So you want to find out How many treatments can it do before it starts having problems? What does the cooling system look like? You know, do people have problems with overheating or not? That's number seven.
So far, I really like the ones that we touched on. There's not just one cost. There's a lot of hidden costs. It's not just that the number that they quote you is the one you should be going off of. Number one is the cost of the device. Two is the per-use fee, which can add up. Three is replacements, which can be unexpected. Five, you mentioned, is portability.
If you have to move it, that's an unexpected cost. The exit is an unexpected cost. I like that you're thinking about this. It's not just there's one number and then you're comparing all the numbers. It's really thinking through what are you using it for and what makes sense.
These are costs that the TMS manufacturer might not be all excited about telling you. You've got to get a heads up. It's good for people to have a heads up about this. Number eight, And this one's a little harder to explain, but you've got to think through who the salespeople are from the company and how is that going to affect your practice. And I have a little true anecdote that I heard from somebody a while ago, and the company will not be named.
I'm excited to hear that. Yeah, I know. Yeah. So, and I'll tell you once we turn off Zoom, I'll tell you who this was. But so what happened was there's this network of TMS centers in a large metropolitan area. And the network of TMS centers wanted to expand to a new location. So they found two or three doctors in another location, started talking to them and like, hey, let's set up a practice with you guys and we'll put a TMS machine in your office and you can be one of us and you can work with us.
And it seemed like a pretty big, pretty good deal. So along the way, you know, they were going to put, I'll call it brand X. They're going to put brand X of TMS machine in that person's office. And And of course, you know, the salespeople from Brand X had to go to that other office to help set things up and make sure that the physical setup was okay.
But here's the deal, is that the salespeople from Brand X had some incentive model where if they added a machine to an existing practice, that had a small commission, a small sales commission. But if they sold the machine to a brand new practice, that was a larger commission. So the salesperson, being the type of person that that person was, talked those other doctors into not joining the network.
So basically the network said, hey, I'm going to give you more business, the brand X. Brand X went around, stabbed the network in the back. Oh my God. And talked those doctors into not joining the network and doing TMS on their own, just on their own, with their own practice. So yeah, so being undermined by your own equipment manufacturer, that's a thing. That is definitely a thing.
And I can tell you that this story has a very pleasing punchline, which is after that happened, one of the managers from the network Call to those other doctors and we were still friends with those other doctors even though they decided to not work with us. But the manager called those other doctors and basically talked them into not using brand X. You know, there's all these advantages to brand Y.
Here's why you should use brand Y. So the other doctors were persuaded and they still did not join the network but they used brand Y. So the person who from the salesperson from Brand X got no commission at all. Boom. And you know, I know this makes me sound so petty, but judge me if you will, but that made me happy. Absolutely. That made me happy to hear about that ending.
So yeah. Anyway, all that's to say, you know, are the salespeople, if you're associated with that company, are they going to undermine you? Yeah. And that is a thing.
Pay attention to the grease factor.
Yeah, exactly. Pay attention to the grease factor.
Yeah.
So drum roll. Drum roll. Okay. So the last one is ask around. Ask other people. Because a lot of these things I've been telling you about are things that you can't really find out just by asking questions. You can't just... Some of these things are like... You got to hear things through the grapevine. So the thing you have to do, the most important thing you can do to find the right machine is to ask your friends.
You've got to ask around. You've got to ask your friends. And I don't mean a couple of friends. I mean a few friends. Ask your friends. And if you don't have any friends, then So if you don't have any friends, this is a darn good time to make friends. And there's a lot of places you can do that. There's online communities of TMS practitioners. There's the OzMind community.
Shout out to OzMind. They have a good online community. There's communities on LinkedIn. There's the Clinical TMS Society. You know, just calling other people, you know, just find people, find people who are doing TMS and ask them, ask them, what do you think about which brand I should buy? Which brand do you use? Are you happy with them? Are you not happy with them? What should you do?
And I think, you know, I mean, physicians in general, providers in general, you know, social providers, you know, physicians, nurse practitioners, physician assistants, there's sort of a culture of mutual cooperation and trust among providers. So they're going to tell you the truth, you know, even if they're going to be your competitor, I think they're going to tell you the truth, you know? So find out, you know, us providers, we need to stick together.
We need to stick together and we need to continue to tell each other the truth. and help each other out. And that's really important. So basically, ask around. Ask around and find out what to do.
All right. Well, this is a great list. Thanks so much for walking us through, Dr. Harvey. And afterwards, I'll be asking what those companies were. But let's call it a wrap.
Sounds good. Sounds good. Hey, sir. Thanks for being here, everybody. Hope you enjoyed the episode. And if you didn't, then, you know, I have some sad little violin music here, and I'm going to play that just for you. So here we go.
Music Plays