kinda chaos: reflections on 2022
2022 was supposed to be the breakout year. The stage was set for smooth sailing. The business was well-capitalized for growth, a baby on the way, and it was time to reap the rewards of years of hard work. Instead, I’m limping across the finish line — an appropriate analogy since I bonked a marathon attempt to start the year. 2022 was a cage fight, and I’m chocked full of lessons learned, though some of them require a bit more distance to share.
leadership: uncertainty and frustration
The leadup to 2022: At the end of 2020, I established a board of advisors and stepped back from daily operations at Green Hill. My plan was to build a new mental health company specifically to serve colleges and universities, a concept dubbed AIM Higher Ed. The board pointed out that I needed to gain psychiatry experience and run an in-network integrated care practice. Instead of continuing to ideate on the perfect solution for colleges, the board urged me to get a proof of concept, and thus Advaita Integrated Medicine (AIM) was born. AIM served two main goals (1) to provide psychiatry to Green Hill’s patients and (2) to serve as a proof of concept for AIM Higher Ed.
I recognized the insufficiency of the Green Hill model. Specifically, it’s the inability to meet patients at various stages in their recovery journey. For me, the exciting part of healthcare is moving people along the continuum from suffering to flourishing. To accomplish that, I want to deliver population-specific, whole-person care. On top of that, I believe operating within the confines of established boundaries (aka insurance) is imperative to serve future generations. Armed with a clear strategy, it was time to get going.
I provided AIM growth capital and launched in November 2021. The capital was supposed to allow us to take a long-term orientation and avoid growth stressors, aka sweating the month-to-month cash flow of a bootstrapped company. We started 2022 with insurance contracts, a steady flow of new patients, and a clear plan. 2022 was going to be a year of consistent growth fueled by lessons we’d learned from launching Green Hill. If only…
Uncertainty was the thing that was consistent in 2022. Long story short, my lack of operational and financial oversight led us into a precarious situation. One of the core functions of a CEO is to deliver performance – I failed April-September but rebounded successfully at the end of the year. Here’s what went wrong:
Capital allocation was bungled between spending significantly on CAPEX and hiring ahead of demand, both administratively and operationally. The road to hell is paved with good intentions.
Cash flow management and reporting were botched as we learned how an in-network practice operated. Revenue cycle management is the name of the game – you have to collect money in a timely manner, or you’re going to be out of business.
The financial issues obfuscated the main operational issue: underutilization of providers. This led to a whole host of problems. Once the financial issues were addressed, it was clear that we were not operating efficiently.
Attention was turned to the underutilization issue, which led to some “culture challenges.” The expectations hadn’t changed since the very early days, but there was zero accountability. When we started to discuss “the numbers,” there was a backlash, and rightfully so. Example: your job description says you’re supposed to do 20-25 hours of billable clinical services per week. You never do more than 15. You’d expect some sort of performance improvement/counseling, right? At a minimum, you would expect no one else to be hired until you (and others) met the number of hours agreed upon, right? Well, we missed the mark on hiring discipline and the courage to have difficult conversations.
I completely underestimated the administrative complexity involved in growing from a largely cash-pay business model to one primarily focused on insurance-based care. We had more turnover in Q2-Q3 than we had in previous yearlong periods. There were a lot of people figuring things out for the first time, and I certainly could have done more to set people up for success. This was felt most acutely in the back office – admin, HR, and finance.
Increased complexity led to over-intellectualization, a constant problem-solution mindset that overlooks the humanity of what we do. Too many people were in stretch roles, trying to operate a more complex system without the necessary training and experience. This was part of the utilization and accountability issues mentioned above.
We measure certain things (like utilization, patient care hours, etc.) to keep our financial affairs in order without interfering with clinical judgment. Talking about our work in terms of billable events, CPT codes, RVUs (relative value units, for those unfamiliar), etc. feels icky. I don’t even like talking about it. That said, pretending that we are not in the business of healthcare is disingenuous. – from provider utilization: where business & care collide
So, how bad was it? There was a time when I didn’t know if we were going to make the next payroll. Many of my mentors and advisors told me to do a round of layoffs, “cut faster and deeper than you think is necessary,” they warned. I ignored their advice, choosing to trust in my own understanding of the situation and the ability of a few key members of the team to pull us through. While I had lined up an equity investor to avert a crisis, I am glad I passed on the deal. Extreme financial uncertainty coupled with a new baby at home = the most stressful experience of my life. For additional thoughts on the tumultuous 2022, check out notes on growing too fast (lessons learned)end of a four-year business partnership. This is my second breakup of this sort, and it wasn’t easy. Ultimately, I think this was the best outcome for myself and my former partner; however, this sort of relationship transition is never easy. I’m eternally grateful that the friendship outlasted the business partnership.
The positive spin: There is a different perspective I could take, one in which we successfully made a large strategic pivot. We’ve more than doubled our monthly revenue and become much less fragile. Instead of 90% of our revenue coming from private-pay services, only 20% does. I also believe we are doing “what the world needs,” not only catering to the 1%. I look forward to exploring that narrative, but I’m going to deliver consistent results to restore my confidence first.
life: parenthood and joy
Nothing beats being a father. For decades, I said I wasn’t interested in having kids. As I got older, I became less resistant to the idea, but intellectually, it didn’t seem like “the right thing to do” (ya know, my existential angst: adding humans is an excellent way to perpetuate the ongoing environmental crisis, there are already so many people in need, etc.). Kelsey and I had our first child in April, and it’s safe to say that life will never be the same.
“Don’t make any major decisions regarding the business until after your daughter is born,” Greg Ng, CEO of Brooks Bell, told me as I contemplated raising capital this summer. Wise words…
How’s fatherhood going? It’s infinitely more challenging and rewarding than I imagined. The first month was a blur, months 2-3 were frustrating, and since then, it’s gotten better every day. I assume mothers are typically more natural caregivers than fathers, but this felt amplified, given Kelsey’s line of work. Want imposter syndrome? Try raising a baby with a speech pathologist who primarily works with young kids and specializes in pediatric feeding.
The biggest challenge this year was separating my work life from my home life. I love my work, but facing financial uncertainty during the first few months of parenthood royally sucked. I struggle to balance my work commitments with helping around the house and spending quality time with my wife and daughter, but I’m getting better at it, I think. It’s early in my entrepreneurial journey, my wife is finishing up her PhD, and we’re starting a family — it’s unreasonable to think this wouldn’t feel like a “busy season.”
I’m fortunate to have a happy, healthy child and a wife far more qualified than I am to raise her. 2022 delivered.
contemplative path: integration + embodiment
2022 was characterized by integrating, embodying, and deepening prior insights. In 2020 and 2021, I had a few “big ah-has” regarding self (or the lack thereof) and what it’s like to see the world without separation (the nondual view). There were some dramatic moments of profound insight and mundane moments that felt extra real. 2022, especially the last few months, felt like a “special” time on my contemplative journey. I can’t pinpoint an exact shift, but my relationship with grasping for insights or striving for enlightenment has changed.
Meditation has been the focal point of my contemplative practices for the past few years. I sat a 7-day Zen retreat in 2020 and then a 10-day vipassana retreat in 2021, both of these were foundational in building my mindfulness practice, and the vipassana retreat produced some significant insights. That said, I’ve always felt striving towards my meditation practice– if only I meditate long and hard enough, I’ll have a breakthrough, and my world will be forever changed (ah, the promise of enlightenment). While I still meditate daily, it’s no longer approached as an Olympic sport. If enlightenment is possible, it must be possible no matter what is being done by the body-mind, enter self-inquiry.
I was introduced to self-inquiry when I was given the book I Am That six or seven years back. The dialogues and nondual pointers contained in that book went right over my head. Since then, I’ve consumed lots of books, lectures, and dialogues on different types of self-inquiry (e.g., Ramana Marharsi, Nisargadatta Maharaj, Loch Kelly, Adyashanti, Douglass Harding, Sam Harris). My interest in self-inquiry grew proportionally with my meditation frustrations. I couldn’t seem to get out of my own head – meditation was just one conceptual thought after another. I was always a meditator striving for something. Through self-inquiry, I’ve been able to penetrate that feeling of being a separate self, and do so predictably. Unlike prior “meditative insights” that seemed random, the use of self-inquiry leads to predictable results. I don’t think I could have gotten the whole self-inquiry practice without increasing my mindfulness through meditation.
Ashtanga vinyasa yoga got me into the whole contemplative world. I started practicing at the end of 2014 and threw myself into the asana practice for the next five years. While I also developed a daily meditation habit, I was mainly engrossed in the physical ashtanga practice. I became disillusioned with the “ashtanga world” sometime around 2018. The mainstream ashtanga hierarchy seems to put gymnastic accomplishment on a pedestal while only paying lip service to the other limbs of yoga (meditation, pranayama, etc.) While I continued to practice, it was a very abbreviated asana practice compared to the prior years. This year I got back into the physical practice. My orientation towards the physical practice and the role it plays in my contemplative journey have changed thanks to meditation and self-inquiry. Now, I find that asana practice is an ideal opportunity for continuous self-inquiry. Can the practice occur without creating a doer? Who and where is the one who strives? Where is the line between physical sensation and the perceiving source?
The three prongs of meditation, self-inquiry, and ashtanga make up my current contemplative path. For the first time, it feels like my practices are serving me and those around me (potentially more important). In the past, it often felt like I was serving some sort of dogma for the sake of “truth” or “being spiritual.” There is an opportunity for the present moment to be perfect, as it is, if we only allow it to be.
Here’s to being, not doing, in the present moment…
lessons learned
Knowingly make tradeoffs. You’re not making a strategic decision unless you are consciously saying “no” to an alternative. You can’t hedge every bet. Look for who and what you are going to bet on, then deliberately move forward. Give yourself enough time to evaluate the decision/bet. You can’t judge the effectiveness of the decision if you’ve constructed a nearly reciprocal hedge.
Should have learned this one from Solomon: you can’t split a baby. When growing a business, you either need (1) to run it by traditional metrics (run a good, clean operation) or (2) to have enough capital not to worry about short-term finances and cash flow, and focus on growth metrics.
Learning involves tradeoffs between time, money, and risk. Want to learn super quickly? Jump in headfirst without experience, just know that it could be an expensive and risky endeavor. Want to de-leverage your learning? Go to work for a large organization, and you’ll be rewarded for your time with money.
looking ahead to 2023: doing less / doing more
scrolling and consuming / writing and creating
working on the weekends / traveling with family
creating new, shallow relationships / investing in existing relationships
asking for advice / trusting my gut (+ analysis)
managing egos / acting with kindness and providing clarity
to the team
First and foremost, I’m incredibly humbled and grateful to be surrounded by such talented and compassionate people who dedicate their professional lives to the service of others. I’m acutely aware that my view of the organization is inherently limited: it’s my individual perspective. So as I reflect on the year, I acknowledge that your experience differed from mine, but I hope some of these themes resonate with you.
2023 was summarized by our core value: growth. Our team more than doubled in size over the course of the year, including a fivefold increase in our medical team, a tripling of our clinical team, and a doubling of our administrative team. In addition to our team growth, we also saw tremendous growth in how we serve our patients. We added an adult intensive outpatient program, transcranial magnetic stimulation, and a team of outpatient therapists, each bringing their specialties and interests to serve the community. That is a lot of change.
A more cynical person would say 2022 was chaotic. “Chaos” is loaded with negative connotations, so I’m going to avoid that word. I certainly felt tremendously unsettled for large parts of the year. Any time a system becomes exponentially more complex, you’re going to have issues with communication, systems, and organization. We experienced plenty of these issues. That said, I’m incredibly proud of how we navigated these challenges, and I know we did a tremendous amount of good for our patients and the community. We morphed from providing services to delivering a system of care – that’s no small feat.
2023 we will embrace our core value: groundedness. We need our systems and communication methods to catch up to the added complexity. It will be a year of refining how we work with our patients and each other. We have laid a phenomenal foundation from which truly transformational work can be accomplished, now it’s time to fill in the gaps. Handling human issues at the human level.
My mantra for the year is kindness and clarity (+ heart). Kindness is about recognizing the humanity in what we do, relating to each other on a personal level, and acknowledging that everyone is doing the best they can. Clarity is about transparency and accountability – ensuring that expectations are communicated and following through on our agreements. It’s about focusing on what is in our control – the work we do – and letting go of what isn’t in our control, the fruits of our labor. I want to wrap up next year feeling like it was a year led from the heart, not the head.
We continue to be on the front lines of a mental health crisis. We get up close and personal with grief and loss. Our mission is to transform personal suffering into human flourishing, and we do a lot of that.
Looking forward to a kickass 2023 with y’all.
If you enjoyed the above, consider signing up for my biweekly newsletter through the link below.
