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An eye surgeon who used to see forty patients a day now sees one to three in a morning, and he has no staff. Oren Fass, a board-certified ophthalmologist and cataract surgeon, has been an employed physician, a practice owner, and an owner who sold to private equity, and he now runs a solo micro practice. He also created The Autonomous Practice Blueprint, a course that teaches physicians how to build a practice that works for them. This episode is based on his article “The hidden variable in the physician burnout debate,” published on KevinMD. You will hear how his agents read incoming faxes, start the scheduling, and apply his billing rules, and why he says this was not feasible three years ago. He is direct about why doctors feel stuck, from the six to twelve month timelines on licenses and insurance panels to the second shift of charting that starts at six in the evening. He also argues that ownership and creativity are the two bets worth making now, and that the salaried job may be the riskier one. You will hear where he thinks the model fits, and where it does not.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Oren Fass. He’s an ophthalmologist and cataract surgeon. Today’s KevinMD article is “The hidden variable in the physician burnout debate.” Oren, welcome to the show.

Oren Fass: Thank you so much for having me, Kevin. I appreciate it.

Kevin Pho: All right. So let’s start by briefly sharing your story and then telling us why you decided to share this particular article on KevinMD.

Oren Fass: Well, my story, essentially, is that I’ve held every possible position within ophthalmology. I’ve been an employed physician. I’ve been an owner. I started my own private practice in 2011, built it essentially from scratch, added employees as it grew, and it got bigger into a multi-office practice. Then I sold that practice to private equity. I stayed with private equity as an employee again for a while, and then I left and started my own practice from scratch once again.

This time I’m doing everything and wearing every hat. But instead of replacing myself with employees, I replaced myself with automations at each station. So it is a truly autonomous type of practice where things are handled electronically, and it allows me to spend a ton of time with each patient, to function in an unpressured manner, and to practice a very different type of medicine that I don’t think people have contemplated or really experienced before. I’m trying to get the word out that this is now a possibility within medicine.

Having held all those other roles in medicine, I’ve had varying levels of happiness throughout the course of my career. Sometimes it was very good, and sometimes it was extremely difficult. I’m very aware of the fact that many physicians are struggling. They feel that they’re trapped, they can’t get out, they’re in a bad situation, they dread going into the office every morning, and they’re having real difficulty.

I think what I’m doing with my practice right now is a type of option that just doesn’t surface in the conversation where you typically hear about physician burnout. There are many solutions that are offered, and there are many thought processes that people go through while they consider what to do, especially if they’re in that situation themselves. But I don’t often hear of this option, and that’s why I’m trying to get the word out that it does exist right now. It’s a very, very different type of practice than what most physicians are used to.

Kevin Pho: Before talking about your article specifically, give us a description or an example of what makes your practice special. You said that there are a lot of autonomous services. So in the life of a cataract surgeon, what exactly does that mean, and what does that look like?

Oren Fass: It is a very focused practice, and from the beginning to the end of the patient encounter, everything that can be automated is automated. It’s a micro practice. It handles a very small volume of surgery and a very small volume of patients. For example, my morning from 9 a.m. to 11 a.m. is devoted to seeing one to three patients, which is very atypical. I come from a background of seeing 40 patients a day. That was a very, very typical day. This is the reverse.

Essentially, I introduce myself to a very small number of referring doctors in the area. I let them know it’s a special practice that functions like a concierge practice, but without the fees of a concierge practice. The reason it works is that the overhead is so dramatically different from a regular practice that there’s no comparison between the two models. In this model, there’s the rent, there’s the equipment, and that’s about it. There’s not much more than that.

I let the referring doctors know that the best way to schedule their patients with me is to send me a fax of the patient information, and I have automation set up. I have HIPAA-compliant software that monitors my fax line. It has Anthropic living inside of that agent. It’s an agent that functions on my computer. It reads the fax in a HIPAA-compliant environment and decides whether the patient is in my EMR yet. It cooperates with my EMR and figures out if it’s a new patient. If it’s a new patient, it sends them a scheduling text message and begins the scheduling process for that patient. That’s just one example of how things are handled through agents and automations rather than through the traditional mode.

I make that very clear up front to the referring doctors. I let them know, “Your patient is going to have an experience that is worlds above being pushed through a mill, waiting half an hour for their appointment, having multiple people dealing with their information, and feeling unsure the entire time. They’re going to spend the morning with me. I’m going to do all their measurements. I’m going to take care of everything for them, and I’m going to answer every single question they have. They’re the ones who end the appointment. They’re going to tell me when they’re done.”

What that accomplishes is that it makes a very different world for both the patient and the physician. As a physician, I feel zero pressure every morning to be done at any particular time or to be under any type of constraint at all. And for the patients, my most common referral is the spouse of the patient I just saw, because they are astonished that this model exists and that this can possibly be happening. The reason it can happen is the automations, which take care of about 80 percent of what a large staff would normally handle.

Kevin Pho: In your KevinMD article, “The hidden variable in the physician burnout debate,” you go through the different iterations of the practices you’ve been involved with before eventually settling on what you do now. A lot of other physicians, I presume, are not doing what you’re doing and are in one of those other employment arrangements. It could be an employed physician, it could be a traditional private practice, or it could be something owned by private equity. Tell us about some of the challenges they’re facing that aren’t readily apparent, challenges that you yourself experienced.

Oren Fass: It’s very different for every field, and all I can do is base what other people might be experiencing on my own experience. But certainly from reading the statistics, the general sense of ennui, the general sense that this just isn’t working out for me, is very palpable in the medical community.

My own personal experience was in jobs where I felt there was no easy way to get out. Once you have the responsibilities of a parent and the responsibilities of a mortgage, it can be very difficult to switch jobs in medicine, because timelines are enormously delayed in medicine. If you want to make a switch, get on insurance plans, be able to earn something from those insurance plans, discontinue your past ones, and update a medical license in a new state, all of those things are six- to 12-month considerations. So it’s very difficult to move. It’s very difficult to jump out of a spot, and people do feel like they’re stuck.

They may have a daily rotation that’s just impossible for them. They may be stuck in a situation where they are doing surgery all day and feel like it’s at the limit of what they can actually do. They may just be in a difficult situation where the equipment is not exactly what they would want, but they have very little control over their situation. I’ve encountered some of those things, and I suspect that’s at the root of what a lot of other people encounter.

And of course, there’s the administrative burden, too. I’ve met with primary medical doctors who tell me they have a second workday that starts at 6 p.m. when they get home. They do their charting and all of those things, and that’s their family time, and that’s how they’re spending it.

So I think it is different by specialty and depending on your situation, but there certainly is this sense that people feel stuck, that there’s not a good option for them, that it’s difficult to jump out of where they currently are, and, even if they could, what’s the better spot to choose?

I feel that many people may be stuck in that situation, and that’s why I’m enjoying letting people know that there’s something a little bit different that probably was not possible two years ago. What I’m doing right now probably was not really feasible two or three years ago. It’s something that is just arriving, and I’m curious to see if, over time, more physicians, especially physicians who are currently unhappy, are going to explore this model and say to themselves, “Well, what would it look like if I arranged everything based on what made me happy and what made my day work for me? Does such a model even exist, where essentially my focus is myself and my patients?”

I want both of us to walk out of the examination happy, with the patient feeling that it couldn’t have been done better and that all the time they needed was spent on them and their concerns. I think that has been missing from medicine for probably decades. So it will be interesting, now that it resurfaces as a possibility, to see if more physicians become interested in it.

Kevin Pho: When you said that your practice wasn’t possible two years ago, I’m going to assume it’s because of the advances in AI. You did mention Anthropic and AI agents. As we all know, it’s moving at such an exponential speed in terms of what AI and AI agents can do. Tell us about the learning curve it took for you to completely automate your practice and to learn the ins and outs of what Anthropic and AI agents offer. How did you learn all that, and how long did it take before it was ready to go into production?

Oren Fass: The learning curve was zero, with a graph line going directly upward, because essentially, in this type of practice, anything I can’t automate is going to fall to me or to a virtual employee I would hire to take care of it. So the impetus for me to automate is enormous. Anything I can automate is taken off my plate or taken out of the category of things I’m going to have to pay to get done.

So I did have a second job at night. The second job at night was learning agentic AI: how it functions, how it dovetails with HIPAA compliance in a medical informatics environment, and how that all can work out. That’s the big challenge of doing this within medicine. But HIPAA-compliant programs that bring artificial intelligence into medicine already exist, and you can begin to get them working on your systems and really taking care of things.

It did take quite a bit of time, and it’s not over yet. Every weekend I spend a little bit of time updating them, because they change and advance continuously. Every week it’s a little bit better than the last week. Even if there’s no upgrade in the systems I’m using, I feed back into the artificial intelligence any area they missed, any area I’m overseeing where they’re not perfect. Feeding that back into them creates what I like to call a continual mind: a billing mind, a scheduling mind. They are continually expanding the prompt they’re working off of, and that makes them better and better every week, even without updates from the particular companies.

Kevin Pho: I want to take a moment here and really underscore what you said. It’s a different mindset, right? Whenever we think about tools, we want them to be a complete process, but whenever we use these agentic tools, or anything AI, it has to be more of an iterative process. I use a lot of AI tools in running the KevinMD platform, for the articles that I accept, for this podcast, and for transcripts. Like you said, exactly, it’s an iterative process that constantly learns every time you update the prompt. It learns your preferences, and it learns what you change. So it’s never a finished product whenever you use these agentic tools.

Now let me ask, what are some of the limits of this approach? You are, like you said, a relatively niche practice. Do you think it could be applied to something like what I do in primary care?

Oren Fass: I really do think there are going to be some universal applications, and there are going to be some things that segment into buckets that are more specific to each specialty. For example, the program I have now that looks at billing takes billing reports and applies billing rules to them. That is something I would look at in different buckets for different specialties, because the specialties have different procedures, and there are different rules regarding those procedures. So I have it set up so that it really does differentiate which specialty you’re in.

But some things are much more general. For example, the automations I have around voicemail and fax intake can be very, very similar between different practices. Different specialties all essentially have a model of getting information and having to sort through that information, and it can be very generalized in that way.

Kevin Pho: Do you see any irony in how advanced the tools you’re using are, state-of-the-art and cutting-edge in 2026, yet you take referrals by fax?

Oren Fass: Yes, there’s enormous irony there. It’s essentially like retrofitting modern tools to handle something that probably should have expired about a decade ago. But that’s where it is in the medical world. I wish we could get away from faxes, but they make up the backbone of communication.

Kevin Pho: Tell us the type of physician your approach would be right for, and the type of physician for whom it may not be the best fit.

Oren Fass: It’s interesting, because people have contacted me, and I’ve gotten a lot of questions about where this can fit. I think the easiest fit is a small office, either medical or dental, that’s very similar to mine. So not a huge volume of patients, maybe even a traditional startup office or an office that’s closer to the modality I have, where it’s not planning on being an enormous office. Then you can designate a person there to be in charge of the automations, to oversee them and introduce them, so that you can have automation in the majority of your systems.

I think the trickier fit is the giant practice that is really looking for a software-type solution. In other words, “We’ve got 300 voicemails a day. Can we solve this?” That’s a trickier fit, because they’re really looking for a software vendor and a software solution. What I have is essentially a knowledge base of how to control agents and apply them to the medical world. That’s not exactly software. It’s more integrated with the process than a typical software acquisition would be. So I think that’s the differentiator between where it works really well and where there can be challenges.

Kevin Pho: How about for the physicians themselves? Like you said earlier, a lot of physicians graduate with hundreds of thousands of dollars of debt. They have a mortgage, young children, things like that, and they may not be in a position to take the proverbial risk of doing what you’re doing. They may be stuck in their job because it does provide a steady income, but of course, with all the strings that are attached to that. Are there any characteristics of the physicians themselves that determine whether they should take this leap or not?

Oren Fass: I think there is a uniting personality and a uniting principle for those physicians who do decide to go off on their own. There’s always been a certain segment of physicians that say, “All right, that’s it. I’m starting my own thing. I’ve reached the limit of what I can do as an employee, and now I’m beginning the next stage.” And that is a huge step into the unknown.

In the coursework where I teach, I focus on those physicians so that they can understand how to do it, and it is daunting for everyone who contemplates it. I try to provide some of my life experience, having done it twice, having left and opened a practice twice. There are some things that do work in your favor. It’s not a total step into the dark.

I always tell people they obviously have to consult an accountant and an attorney to get the true details based on their own situation. But when I did this in 2011, because you’re taking on so many equipment loans, there was the process of essentially saying, “Well, I earned this much from my job where I was an employee, and taxes were automatically going to the IRS, but now I have losses. I’ve invested in equipment.” Those things can give you a tiny little bit of buffer to make it through a few months, and they’re worth investigating with your accountant or whoever’s handling the legal part of your structure, because that does give you a little breathing room when you’re taking that first step into the unknown.

I would never push someone to take that jump. That’s something everyone has to decide on their own. But here’s my thought, and this is what I tell my kids, too, who are now getting to be college age: Even if you assume maybe a 2 to 5 percent advance in artificial intelligence per year, which I think is low, it’s already doing almost everything you can sit down and do at a keyboard at a computer. So I encourage people to think of ownership and creativity as the two pillars going forward. I would not rest 10 years’ worth of study and an entire career on something you’re doing at a keyboard and a monitor right now.

I think the risk of going off on your own and being an owner may begin to pale in comparison to putting all your eggs in the basket of, “I do these tasks at a computer, and that’s mostly what I do.” That might be the riskier bargain as the world moves forward over the next couple of years.

So that’s the way I look at it. That’s how I advise my family: Yes, there is risk in entrepreneurialism. There always has been, and people have always taken that step. But in my mind, the calculus has changed in the other direction. I think it’s becoming a little bit riskier to take the safe route of, “I’m just going to do what I’m paid to do in my job,” when 80 percent of it takes place at a computer screen and a monitor. That is the area where I think risk is building over the next couple of years.

Kevin Pho: We’re talking to Oren Fass. He’s an ophthalmologist and cataract surgeon. Today’s KevinMD article is “The hidden variable in the physician burnout debate.” Oren, let’s end with your take-home messages to the KevinMD audience.

Oren Fass: My take-home message would be that agentic AI is already here. It’s not a futuristic development. We’re living through it right now. It’s already present and able to be used inside medicine, and my opinion is that the physicians who are aware of it, begin to attune themselves to it, and take advantage of it are going to have advantages in the future as it continues to mature and become part of the environment.

Kevin Pho: Oren, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

Oren Fass: Thank you so much, Kevin. I appreciate it.