Todd:  Thank you so much for joining us here on Scrubbing In. I’m Todd Schlosser, and joining me today is Dr. Greg Lanford, a entrepreneurial neurosurgeon from here in Nashville, Tennessee.

Todd:  Dr. Lanford, do you mind if I call you Greg?

Dr. Lanford:  Greg is great.

Todd:   All right, perfect. Then I’ll do that.

Todd:   I’d like to start off by asking the question I usually start off with, and that is what is it that drew you to healthcare as a field in general, in your youth?

Dr. Lanford:   When I was growing up in the ’60s and ’70s most male children, at least, if their dad was a physician, they became a physician. My dad was a general surgeon and that’s how I was interested initially.

Todd:  Awesome. So I guess you grew up around it then? There’s nothing better than having a mentor who’s in the house, right?

Dr. Lanford:   That is correct.

Todd:  So did he do a lot of mentorship with you when you showed an interest in it?

Dr. Lanford:  When I showed an interest, he never really pushed it. I had three older sisters who were all extremely intelligent, all could have been physicians and at that point in life, in the ’60s, that was not encouraged. But since I was the male child, I was encouraged to be a physician. And at that point in time, physicians were held in very high esteem. There was great job satisfaction, it was a different environment than it is today, and so it was almost a no-brainer.

Dr. Lanford:   But he didn’t have to force it on me, because he was so revered and you were proud he was your dad.

Todd:   Yeah, I definitely understand that, and it has changed a lot. I remember even when I was growing up in the ’80s, doctors making house calls wasn’t super uncommon, it’s something you heard about, but I guess it was being phased out over the course of that time, and doctors as a pillar of the community.

Todd:   I still think largely they are, but the touchpoint was more out in the community back then and now it’s more centralized at the hospital.

Dr. Lanford:  It was a lot less complicated time in regards to interactions with patients, as well as interactions with industry, with insurance companies. Basically you did your work, you knew what you were going to get paid, there wasn’t a lot of bartering and it was a different era of medicine.

Dr. Lanford:   And I think what got me interested in where I am today, in regards to the business and medicine, is just the evolution that I’ve seen over my lifetime.

Todd:   Yeah, let’s table that until a little bit later because I do want to talk about that. But I’d like to talk about when you decided to go to… I believe it was University of Alabama, correct?

Dr. Lanford:   University of Arkansas.

Todd:   Oh, excuse me.

Dr. Lanford:   There’s a story in and of itself in that.

Todd:  Oh, is there? What’s that story?

Dr. Lanford:  Well, when I grew up, I basically grew up in Memphis. I went to prep school in Memphis, seventh grade on. I actually grew up across the border in eastern Arkansas and public education there was not the greatest. I went K through six there and it had its problems.

Dr. Lanford:   And so I went to school in Memphis. And my dad knew I was going to go to med school, I was going to be a surgeon, those sorts of things. And he gave me some unusual advice. He said, “You’re going to do well enough to get in med school, you do well on tests, you’ve done well in school. Getting in med school is not going to be a problem.”

Dr. Lanford:  And at that point in time, in the mid-’70s, all the elite schools were looking for kids from Arkansas, or West Virginia, or the downtrodden states, so to say. And so, you know, instead of going to Harvard or Yale, he said, “Don’t do that. Go have fun for the next three or four years, because after that it’s going to be business.”

Todd:   Because med school is no joke.

Dr. Lanford:  Right. And so I said, “Well, that sounds reasonable to me. Sounds like a good idea.”

Todd:   Your dad just gave you a license to go have fun in college.

Dr. Lanford:   So I went to the University of Arkansas and I was there three years, and then he gave me some other advice, which was, “Hey, I want you to apply to med school.” And I said, “Well, I’m only a junior.” I hadn’t graduated yet.

Dr. Lanford:   Well, he had a friend who was on the board at the University of Tennessee and they were in the process of trying to recruit kids from border states. The University of Tennessee’s the second largest medical school in the United States. And so they had competition with Vanderbilt. There was also a med school out in east Tennessee as well, and so some of the kids from that part of the state would go to east Tennessee. Obviously Vanderbilt had a following. And so they were trying to increase their recruitment base, I guess, for lack of a better term.

Dr. Lanford:  And so he said, “Just go ahead and apply to med school.” And I said, “Well, I really don’t want to get in med school this year.” You know, that was part of the reason… I’m staying here. “Yeah, don’t worry about it. You won’t get in,” Okay? “Because you hadn’t graduated.” So I took the MCAT, did well, of course I got in. And so I had to go to med school a year early. So, you know, my four years of fun became three.

Dr. Lanford:   But it was still a great experience.

Todd:  Absolutely. I was gonna ask you actually what took you to university in Tennessee, instead of an Ivy League school. But I guess you’ve answered that question pretty well.

Todd:    Let me ask this though. We were doing some research this morning, and we saw that you initially planned to do cardiac surgery-

Dr. Lanford:   I did.

Todd:   And that shifted. So what was it that caused that shift from cardiac to neurosurgery?

Dr. Lanford:   To do cardiac surgery, you have to do a general surgery residency, at least back then. You did a full general surgery residency and then you did a cardiothoracic fellowship two or three years after that. So after my third year of med school, I decided I’d apply for general surgery, thinking I was going to be a heart surgeon, and got my general surgery residency, University of Tennessee in Memphis, which was a great place to do general surgery because of the trauma center they have there and and various other reasons. But it’s a great place to train. It’s a lot of hands-on experience. Okay?

Dr. Lanford:  During my fourth year of medical school, I did an elective in neurosurgery and I’d never been exposed to that before.

Todd:  So in your fourth year of medical school, you decided-

Dr. Lanford:   And so I’m already matched into being a general surgeon, okay? In neurosurgery you do a different path. You do two years of general surgery, and then you do a neurosurgery residency. And so it was changing tracks totally. But at that point I decided I liked neurosurgery, just the intrigue of it. It was a little mysterious. And I just really had a mentor there in Memphis, a fellow named Dr. Morris Ray, who was an outstanding neurosurgeon, who I had the opportunity to work with my fourth year of medical school. And just decided, “Hey, that’s for me.”

Dr. Lanford:  And so during my one week off of a general surgery internship, I went in and interviewed for neurosurgery residency positions and matched at Vanderbilt, and so I left and started neurosurgery.

Todd:   Yeah, I noticed you did your neurosurgery residency at Vanderbilt, which you completed in ’91, correct?

Dr. Lanford:  Yeah, I did.

Todd:   So did you start practicing at Vanderbilt after that? Or where did you matriculate to after that?

Dr. Lanford:    You know, at that point, my ultimate job, Howell Allen clinic as today, was at that point just named after the doctors. It was Howell Allen and Allen. That was the name of their practice. And as part of the residency at Vanderbilt, we rotated with some of the private practice neurosurgeons in the community out at St. Thomas. And so I spent a year of six years exposed to those guys. I interviewed around the country at some other places.

Dr. Lanford:  I knew I wanted to do private practice neurosurgery. But for a lot of reasons, a comfort level, knowing the guys, knowing Nashville, it just felt like the right thing to do to stay here.

Todd:   So you immediately started with the Howell Allen and Allen at that point. And then I guess eventually just became the Howell Allen Clinic.

Dr. Lanford:  It did. It had another name between that, became neurological surgeons, and it was Howell Allen Clinic.

Todd:   Which you lead, and have led since ’97, correct?

Dr. Lanford:   1997. So when I joined in 1991, my unique skillset as compared to the physicians who were there, is they’d grown up through the time when my dad was a practicing surgeon. You worked hard, and you got paid, and you went to the next thing. You can have patients in the hospital as long as you wanted to. Efficiency didn’t matter. And so during our-

Todd:   It’s not like that anymore.

Dr. Lanford:   No. During my residency, when I started residency, you’d go and literally there’d be four doctors who had 80 patients in the hospital because they were in there for various and sundry reasons.

Dr. Lanford:  Either they’d had surgery and they were staying a week, whereas today those are outpatient procedures. Or they were coming in to get physical therapy in the hospital. I mean, those sorts of things just made zero sense to me.

Dr. Lanford:  And the chairman at Vanderbilt had done some of his training at the University of Minnesota, and Minneapolis was kind of a hotbed for managed care. And the big thing everyone was… Scared, I guess, is the word you should use, about going forward from the mid-’80s was managed care.

Dr. Lanford:   What was that going to do to reimbursement, particularly in healthcare? And what was that going to do with physician-patient relationships? And so it made sense to me, and this is common sense, I’m not Einstein or anything, but it was if you take great care of patients and do it efficiently, it’s patient-centric, they’re gonna get the best outcomes.

Dr. Lanford:   You know, the insurance companies aren’t going to come get you because you’re doing them a favor. You’re also doing the hospital a favor, even though they don’t believe that. It was obvious to me that’s where medicine was going.

Dr. Lanford:    And so in ’91 when I started practice, I spent the first three or four years talking to the other four guys in the practice about, you know, why don’t we shorten our length of stay? We’re going to be graded on this. Literally, we’re going to be given ratings and insurance companies are going to decide who patients are going to go-

Todd:   Yeah, who to send people to, more or less.

Dr. Lanford:  Right. Based on your outcomes and your efficiencies, your cost. And that never really came to pass and it still hasn’t today. But I think it was the right idea, such that over the five years I was by far the youngest person there, the Dr Howell, of Howell Allen Clinic, who had been the managing partner of the practice since it started in 1982, came to me and said, “This is over my head. You obviously have a talent in this, you need to run this.” And fortunately, however many years later, 22 years later, I’m still running it.

Todd:   Well let me ask this, because you touched on better patient outcomes, and how you saw a path for that and it didn’t quite play out in the insurance industry like you thought it would, but it still led to better outcomes. Is that what led you to be sort of an early adopter of neurophysiology or inter-operative neuromonitoring?

Dr. Lanford:  I think all those things were part of it. I think our mantra has been, from the get-go, patient-centered care. If everything you do is based on best outcomes and best care for patients, everything that comes from that, be it patient satisfaction, be it physician satisfaction, be it additional reimbursement, it all follows doing the right thing for the patient.

Todd:   Yeah. I think ultimately it’s all about getting the best outcome for the patient, and the business model that it is out there is set up that way.

Dr. Lanford:  And that’s… It should be.

Todd:   Yeah. So you’ve led the Howell Allen Clinic now since ’97 and then you partnered up with St. Thomas, is that correct?

Dr. Lanford:  If you go historically back to ’82 when Howell Allen and Allen were at Vanderbilt, with Dr. Meacham who was the chairman there, and it was one big group of neurosurgeons in Nashville that took care of the whole town, Vanderbilt and the other hospitals.

Dr. Lanford:   Well, it was obvious to Dr Howell Allen and Allen they were doing a lot of the work, and some of the other doctors were taking a lot of the money. And so they decided they were going to break out on their own and they started at St. Thomas. What’s now St. Thomas West, but we still just call it St. Thomas.

Todd:   Yeah, it’s the original St. Thomas.

Dr. Lanford:   The original St. Thomas. And so they started there. We’ve been practicing there since 1982 and so we have a long relationship with St. Thomas. In 1997, when I started leading the group, I went to them with a business plan and said, “I want to start an outpatient surgery center.”

Dr. Lanford:   That just does spinal surgery. Our patients. And offered that to St. Thomas, but I also offered it to Baptist, which is now St. Thomas Midtown, as well as what was called Parkview then, which is now Centennial, HCA Hospital. And all three were excited about doing it. Obviously St. Thomas had the most to lose because we were doing about 80% of our business there. And so they said, “We’ll sign up.”

Dr. Lanford:   The reason I needed a hospital partner was because Tennessee has a Certificate of Need law and so I was not going to get this passed through the Certificate of Need board without a hospital partner.

Dr. Lanford:   So, in 1999 we opened the first single specialty outpatient spinal center in the United States. And it was called the St. Thomas Outpatient Neurosurgery Center. It’s a 50/50 partnership between St. Thomas Health and Howell Allen, except we weren’t called Howell Allen, but Howell Allen. And so our relationship really, that part of it, dates back to ’99.

Todd:    And that’s a very, I think, entrepreneurial approach to medicine, which I don’t think, and I may be wrong about this and I’m happy to be, but I don’t think a lot of doctors come out of med school with that skillset. Not saying that you didn’t, it may be something that was just ingrained to you or it kind of intuitive to you, but how did you develop your sense for entrepreneurship in the medical space?

Todd:   I really believe that it was formed in my life experience of seeing what things were like and what they had become, and what I thought they might become. And knowing that as long as you kept your eye on the prize, patient-centric, you did things for the right reason, with efficiency, that that was going to be the best model, no matter who ran healthcare.

Todd:   It wasn’t something I learned in school, I don’t have an MBA, never went to business school. But living in Nashville, you’re around a lot of really smart healthcare people, and so I think I’ve learned a lot from them.

Todd:   We actually started an outpatient surgery center company, called NeoSpine, in 2000 which to go with what you’ve said, literally, I bet I spoke to every neurosurgeon in the United States about this company. And every one of them would say, “We absolutely want a NeoSpine center.” The company was called NeoSpine. And it was set up where the doctors had no risk. It was 50/50 non-recourse debt financing, meaning if they walked away, we held the debt. And all the time we did that, you know how many centers we started in the United States? Six.

Todd:  Yeah?

Dr. Lanford:    Six.

Todd:    And it was all the neurosurgeons wanted this?

Dr. Lanford:   Yeah. You should’ve started, you know, 60 anyway. Six. And so to, to liquidate the company, what we finally did was we started buying radiosurgery units, things called CyberKnives. And we sold those to radiologists and radiation therapists. And they all got it.

Dr. Lanford:  And so the exit for that was fine. We sold it to a company called Symbion, which is another company here. But even today, if you have the same conversation we had then, everyone’s excited about it. But you’ll still get people who will not do it.

Dr. Lanford:   And a lot of the time with neurosurgeons, it’s because they are the smartest person in the room. And a lot of times they are. But if it’s not their idea, then it’s not a great idea. And so it’s an interesting dynamic, in doctors and medicine and business. It’s very peculiar.

Todd:   That is a very interesting dynamic. I didn’t think about that. If it’s not their idea, it’s not a good idea, but then-

Dr. Lanford:  Yeah. And they’re also very risk averse. Neurosurgeons are, by and large, very conservative.

Todd:  Well, you’re trained to be, right?

Dr. Lanford:  Yeah. And so most of them are pretty conservative financially. And again though, it’s almost trying to find a reason not to do it, than to do it. And it’s hard to get out of your own way.

Todd:  Yeah, absolutely. So I mean that getting out of your own way is a lot of times, in everything, the biggest struggle you’re going to have as a person.

Dr. Lanford:  Analysis paralysis.

Todd:   That’s a really good mantra.

Dr. Lanford:   And it happens a lot.

Todd:  Yeah. So you mentioned when you started… was it NeoSpine?

Dr. Lanford:   NeoSpine.

Todd:  NeoSpine. And then you sort of offloaded that to a company here in Nashville. There are a lot of healthcare companies here in Nashville and you, not to date you, you have been in Nashville a long time in that medical community and Nashville has grown so much, not just as a city but largely because of the medical infrastructure that we have here.

Todd:    So what has been the biggest change since, say, ’91, late ’80s, early ’90s, from when you started in Nashville until now that you’ve seen, that has caused, that has facilitated that much growth?

Dr. Lanford:   Well, I think two things. First of all, Vanderbilt has continued to expand their endowments grade. And so that’s been a constant. But the spinoffs from HCA have been the thing that have driven the market. The depth of healthcare opportunities here, not just in the general hospital space, but you’ve got companies used in an outpatient surgery, and psychiatric hospitals, and rehab hospitals, and almost all of those are executives who at one time were at HCA, cut their teeth there, and then have gone out and done something else. And it’s just spun wildly.

Todd:  So HCA sort of acted as an incubator, if you will, for all of the healthcare talent.

Dr. Lanford:  It has.

Todd:   And it got everyone here and then as that got bigger and bigger, they spun off other, like Tivity and MEDHOST, and all these other big healthcare brands that are central to the infrastructure of Nashville now. It’s been pretty fascinating to watch over the course of my life and your career.

Todd:  So one final question while I have you here. If you were talking to, let’s say, someone who just finished their residency, and they were looking to take an entrepreneurial mindset to their medical practice, whatever that may be, what advice would you give them?

Dr. Lanford:    I think first of all, if they could find a situation where there would be a mentor who’s done it, who they could learn from, I think that’s helpful.

Dr. Lanford:   Don’t be afraid to hire consultants and know what you don’t know, and allow someone to guide you through that.

Dr. Lanford:   I think that I always knew my limitations in business. I’m not a CPA. I’m not someone who’s going to look at spreadsheets and really get into the nitty gritty of those sorts of things. And so sometimes you have to spend some money to really learn what you need to know about a project to analyze it.

Dr. Lanford:  But don’t be afraid to make a decision either. I think what we’ve seen around the country is people who really, again, look for reasons not to do things instead of reasons to do things. And I think that sometimes you have to make hard decision and go with your gut.

Todd:  Thank you so much, Dr Greg Lanford for joining us here on Scrubbing In. I really appreciate your time with us today.

Dr. Lanford:   Absolutely, I enjoyed it.

Todd:   Thank you so much.

Dr. Lanford:  Thank you.

Todd:   Thank you.