I've probably been along like in TikTok longer
than anyone else. I think that I was the first
psych NP that was out on TikTok making videos.
And I think that's where like the following came
in. So you have these people who come in and
they're like, well, you need to increase your
productivity and see more patients in 15 minutes
and do more evaluations. And I'm like, hey, this
is garbage. I know that it hasn't been easy working
with insurance, right? No, never. They will underpay
us and they expect you not to notice. When people
are on like the PMHNP board saying like, oh,
what's wrong with this person? I think it's a
person. personality disorder it's access to and
like i'm reading it and i'm like they're fucking
autistic like why is nobody asking about that
as the differential it blows my mind sometimes
when i like sit down and look at it because like
i don't know on the day -to -day i'm just exhausted
and drowning and there's just so much to do but
like it did take off and it is it's its own thing
and you know our practice has paved the way for
a lot of similar practices to also be vocal Welcome
to No Prior Off. This week, I'm sitting down
with Dr. Maria Ingala. Maria is the founder of
Paper Flower Psychiatry in Arizona, a 16 provider.
five -location neurodivergent affirming practice
that she launched in October 2020 after a string
of community health jobs that ended in what she
generously calls unplanned career detours. Translation,
she kept getting pushed out for fighting her
employers over pill mill quality care. She's
also a DNP, a perinatal certified psych NP, a
nationwide psychiatric consultant to pediatricians
and OBGYNs, former ASU nursing faculty, and the
co -host of the podcast Brain Trap. trash, psychiatry
from DSM to dumpster fire. And she runs an education
platform called Paper Flower Institute. She's
also the kind of honest that only a mom of two
small children and two dogs named Marshmallow
and Potato can be. If you've ever wondered how
to scale your practice without scaling the soul
of it, scaling out the soul of it, Maria is the
one to ask. Let's go. Also, she recently founded
a nonprofit that we are going to be talking about.
We have so many things to cover, Maria. I feel
like we could meet for like three hours and not
touch it, but we're going to do our part. And
if we have to do a second episode, we can do
that. We're here for it. Thank you for being
here. Yeah. Thanks for having me. I'm super stoked
for this. Me too. I remember like Facebook messaging
you. I think it was probably 2020 because I remember
coming across your stuff and I was like, this
is really cool. Like you wrote an article for
something. I'm sure you remember it. It was 2020
because in 2020, I got fired again from yet another
job and got really feisty and wrote an article.
And that article gained like a mass amount of
media attention, which was crazy because like
it was just written in like spite. Speaking of
which, I didn't even cover that, but you have
quite a media following other than Kojo. Like
as far as Psyche and Peace go, I feel like you
have the biggest media platform, if you will.
I would be. I mean, that's interesting if that's
true. It's I probably been along like in TikTok
longer than anyone else. I think that I was the
first like NP that was out on TikTok making videos.
And I think that's where like the following came
in. I'm not as active now because, as you said,
I have two small children and they make my life
very difficult. Yeah. Yeah. Children do that,
don't they? How old are they? Two and four. So,
yeah. Yeah, both both autistic, both very needy
in their own ways. So lots of work there. I don't
know how you do it. I don't. But we're going
to find out today. We're going to find out today.
I know that you're big on your support staff,
virtual assistants. I want to dive into that.
I want to dive into kind of I mean, you work
with insurance, too. And I want to know about
that because that's another thing that people
struggle with. Do I work with insurance? Do I
not? Do I work with these platforms? Headway,
Alma? What do I do? You know what I mean? And
I think you've built a really unique model. And
I actually love that you are like fully focused
on Arizona and that you're not like multi -state.
Not that there's anything wrong with being multi
-state, but like, I don't know. I just feel like
you can really help on a different level when
you really know your community. Yeah, that's
like the biggest thing for us is like we've always
been very like community based. And when I built
this, it was like I'm going to network with everyone
I can find who will have a coffee with me. And
like if I did that in Colorado or I opened in
Alaska, I mean, like, I don't know anybody. What
am I going to do? Fly out there and be like,
hello, does anyone want to meet with me? Like
I have no presence. So true. You just reminded
me I messaged somebody yesterday. I was like
a provider. I was like, I'd love to do a coffee
chat. And she's like, tell me what a coffee chat
entails. And I was like. well doesn't everybody
want to like that work and get to know other
people I just want to see how we can synergize
but anyway okay so let's first talk about this
foundation that you have founded When did you
get the idea? What's the heart of it? The soul
of it? Like how can other people get involved
both in Arizona and outside of Arizona? Yeah,
I have been interested in like public health
and access to care and kind of dreamed of having
a nonprofit for like as long as I have. been
you know aware of public health so like since
my early college days I ended up like having
this specific idea probably like 2018 2019 of
like how can we increase access to care like
the system is really broken it kind of like continued
because access is a nightmare you really don't
get a choice of providers access very much limits
its panels so like how do we help people to continue
to get good care that they choose while like
you know, sustaining our own practices. I took
a lot of pro bono patients in my practice when
I left community mental health. Like I took a
ton of patients with me and I just kept them
for free. And I mean, like eventually that wears
down on your time and like your income and that's
just hard. So. When I decided like finally, like,
look, I'm going to do this. I kind of like made
this plan of like, OK, so what we do, we're called
Paper Flower Foundation. We are going to offer
financial assistance for psychiatric medications.
You can't afford your copay. You can't afford
your med. We will pay for it for you. For like
people who have high deductible plans for psychiatric
appointments or therapy or people who just can't
afford the self -pay of it. Right. Like you have
an insurance lap. You have a job loss, something
like that. We can come in and we can cover that
for you so you don't have to lapse in treatment.
And then on the other side, we have like tons
of providers that we work with. So we started
like the provider partner network. You can pay
a fee and then come in and we'll reimburse you
like a percentage. So that way you're not doing,
you know, pro bono and sliding scale work for.
like nothing for pennies, right? Right. Like
it's not worth it if you're going to see tons
and tons of patients. It's going to eventually
limit like how many people can you help or like,
hey, I can't continue to like sustain my practice
like this. So we can offer payment for that.
That's fair. That's amazing. So the partners
for like provider partners, they need to be in
Arizona, right? As of right now, I'm very community
focused. And like if we could like move this
model to, you know, expand into like the Southwest
or other states, I would love that. But like
we need to make this model work first. And like
once this pilot works, we can expand it. Yeah,
that's a great point. That's a great point. Okay,
so we can put in the show notes, the links to
the foundation. And people could donate even
if they're not in Arizona, right to the cause.
So if you want to like support this model and
kind of see success in like, you know, an NP
launching a nonprofit that is increasing access
to care and helping people, you want to like
support someone's copay, you can pay for someone's
copay, you can pay for their therapy session,
you can like, you know, let's still be community
partners, you can be our partner. corporate sponsor
without being in Arizona. Just the partners that
we work with for therapists and our people we
help are in Arizona. Okay. And you're also looking
for board members, correct? We have one more
board slot open and then we're looking for advisory
board members. So if there are folks in Arizona
who've had trouble with access to care, you don't
have to be a healthcare provider. Or if you are
a healthcare provider, we are looking for partners
in Arizona and people to do on the advisory board
for partners. Okay. And how do we get the word
out to patients, do you think? It's already like
kind of going. My hope is that like once we get
partners coming in, therapists, psych NPs, they're
coming in with us. They're going to say, who
am I seeing pro bono already? Let me go ahead
and like send them this application so they can
get paid for those people they're already seeing.
And as people come in and they're like, I lost
my insurance. OK, let me take care of you. And
then other than that, the word's going to spread.
Right. Like that's how everything works is word
of mouth. So I have no doubt that we'll have
more than enough applications. We just don't
have enough funding. you need more community
partners and more donations. We need more partners.
Well, it's a really great cause. I saw on TikTok
yesterday, somebody posting like, I think it
was some type of mental health provider. Do you
know of any nonprofits? Basically what you're
doing, but like in other states, it was like
in Alabama and in Alaska. And I was like, well,
I do in Arizona. How did you even get this idea?
Like, when did you get this idea? I feel like
it's just been like coming for a while of like,
what am I going to do? Because like we do this
kind of thing. where we're compensating for people
coming to see our providers, right? We have an
application people fill out. They can get sliding
scale and pro bono. And it's like, OK, this helps
some people with us. Sure. But like what happens
when they can't afford their medication? What
happens when they can't afford their therapy?
They can see us, but that's it. So like this
was kind of like my effort to like kind of create
the wraparound for everybody everywhere. Yeah,
that's really cool. I love what you're doing
there. OK, let's talk about your practice. When
you set out to do your practice, did you set
out to be like I am going to scale a group practice?
Yeah. Like, did you know that you were going
to have like 16 providers and probably more than
that pretty quickly here? Dude, no. Like, I didn't
even want to have a private practice. I didn't
want any of this. Like, I would have fought you
if you told me in 2018, like, you're going to
have a private practice someday and you're going
to have lots of providers. I would have laughed.
Like, I always wanted to work in community mental
health. And like, I only did this because I kept
getting fired. This is my third time getting
fired in 2020 in October. Third time getting
fired? As a psych MP? Yeah. For what? Like, I
don't get it. That's ridiculous. I mean, like,
speaking out. It's like speaking out. Like, I
have authority concerns. So you have these people
who come in and they're like, well, you need
to increase your productivity and see more patients
in 15 minutes and do more evaluations. And I'm
like, hey, this is garbage. Like, nobody's getting
better. Like, how am I going to spend 15 minutes?
Somebody came in, you know. 15 minutes late to
their appointment. See them in two minutes. I
saw children. Like, how am I going to see a five
year old who has like a history of sexual abuse
and haven't seen a provider in two years and
I'm going to see them in two minutes? Like, that's
insane. So I was like, no, this is disgusting.
Yeah. You guys can't make me do this. Give me
longer appointments. Give me more breaks. Give
me this. Give me that. Pay me more. Like, this
is you're exploiting me. How come the psychiatrist
down there is making like six times as much as
me and I'm seeing more people pay me? Right.
So, yeah, they just kept firing me. Yeah. And
so you were like, OK, this is my next step. Like,
I'm not just going to go work for another place
where the same thing is going to happen. Yeah,
I just got a house. So I was like, well, I'm
going to lose my house if I don't. you know,
if I keep getting fired and I was, yeah, I was
supporting my husband through nursing school.
So I was like, let me just make a practice. It's
just going to be me. At the time I had a student
who she was like, Hey, I have somebody else who
wants to pre -step with you. And I was like,
okay. And it was John Frank. And he came in when
I was just launching my private practice. And
like, I ended up hiring him only because he was
my student. Right. Right. Okay. How much money
did you spend? on the front end of like starting
your practice i know it's been a while so it's
probably hard to remember but people ask that
a lot like how much money do you need and what
did you spend money on let me see i paid for
a website so maybe like 100 bucks um i made it
myself and then i paid for like a logo on fiverr
maybe like 20 bucks and then that's it dude like
i paid for like my llc paperwork through zen
business i didn't a telehealth platform so i
just did psych today $29 .99 and that was it.
I never took out loans. I never put down like
hundreds and thousands of dollars. Like I just
organically grew it. And as I got money, I would
reinvest it. So you really launched pretty minimum
viable. Yeah. Yeah. I love that. Were the platforms
around like the headways and the almost in the.
No. So back in the day, I actually did my own
insurance credentialing myself. But I did it
wrong. So I ended up hiring like a credentialing
billing agency after I started to kind of expand
a little bit. And I was like, I can't do this
by myself. I don't understand it. They screwed
me over even more. And like they missed claims.
There were things that were underpaid. They messed
up the credentialing. Like it was a whole nightmare
that has taken me years to come over. So I did
it all myself back in the day, but it wasn't
done correctly. Now I have somebody who does
credentialing for me. Who's that? Or like, you
don't say who, but like it's it. It's my virtual
medical assistant. So I went and I looked for
a person from the Philippines that would do my
credentialing. So she already had experience
in credentialing. I hired her in and she does
all of it for us. Wow. That's incredible. And
she does it right. It's amazing. She does everything
correct. Like she will negotiate rates. And then
she also like crossworks on the billing team
and our support team. That's incredible. Wait,
when did you hire your first support staff? So
I had hired like some people here in the United
States for a while and I had terrible experiences,
like horrendous. Really? Horrendous, dude. Horrendous.
Like. people just like pretending they were working
and like they weren't doing anything, like doing
things incorrectly, like not being professional.
Like it was just horrible. So I ended up hiring
my first like virtual medical assistant through
a company in like 2022. It was 2022. And I like
was talking to him and I was like, dude, how
much are they paying you? I'm paying $2 ,000
a month to have you and you're working overnight.
So he's like $3 an hour. And I was like. I'm
paying $2 ,000 and you're getting $3 an hour.
You can't even support your family. And his wife
was pregnant. And I was like, how are you even
going to like you don't have insurance. You don't
have anything. I fired the company and I rehired
the VA low key and paid for his wife to give
birth in a hospital and paid him $10 an hour.
That's cool. Yeah. And that's kind of like how
I started my VA journey. And now I have tons
of VAs. I don't even know how many like 15. Wow.
And you so you hire them all directly. I hire
them directly. Yeah. So I made a course on like
how you can do this because there's like a lot
of nuances of like, how do you communicate? What
systems can they use in the Philippines? Right.
Like phones, all of that stuff. So, yeah, I hire
everybody directly and I pay them very fairly.
So I actually have like my in -laws are from
the Philippines, like my husband has family in
the Philippines. This isn't like, oh, I'm going
to find some worker and exploit them. This is
like, no, these are my people and I'm not going
to cause harm to people in a culture that's like,
you know, my children's. So it's very important
to me to take care of those people. Yeah. Wait,
so you have almost as many support staff as you
do providers? Yeah. So I have a whole billing
team. I have a credentialing person. I have a
social media person. I have a website person.
Like, yeah. Did it take a lot of like training
of them to? No, like that's like the misconception.
Everyone's like, well, what am I going to do
with them? How am I going to train them? It's
like, bro, they're trained. They've already worked
for places. They come from these companies and
they're looking for like fair pay. Yeah. They
know how to do it. You just kind of show them
the system and that's it. That's incredible.
So your course is for providers who want to kind
of hire virtual assistants directly and how to
do that. Training, like interviews, like all
of that. Like, what do you ask? How do you kind
of vibe out somebody who's lying? Because people
can, you know, misrepresent themselves. So we
go over that. And I have like a little kind of
video of me talking to my VA. So you can actually
see like what the communication style is like
and like how they are as people. That's really
cool. I know that it hasn't been easy working
with insurance, right? No, never. What's been
the hardest part? Dude, they are like, how do
I want to phrase this? They are like so manipulative
and they prey. They prey on us as private practices.
And that's the hard thing is that they will underpay
us and they expect you not to notice. So you
get. People don't really understand it either
when they're doing it themselves. You get a contracted
rate. I'm getting 100 bucks for every med check
I do. Right. So like the insurance will send
me 100, 100, 100 for every med check. And then
randomly they'll start sending me 99. And then
they'll start sending me 9902. And then they'll
send me like 9804. Right. And then all of a sudden
they're sending me $60 for a med check. And then
they're sending me 100. And it's so mixed in
there. And there's so many claims coming back.
And you contact them and you're like, why did
you underpay me? This is not my rate. And they're
like, oops, resubmit it. More paperwork. So they
create these administrative burdens so you don't
notice. And if you don't notice within six months,
you cannot resubmit it. So I lost tens of thousands
of dollars, probably like $30 ,000 to $40 ,000
because I didn't notice on time. And Blue Cross
told me, too bad. You're bad. We're keeping it.
Oh, my gosh. How did you realize it? You just
started looking more closely? So I fired my billing
company and I hired from the Philippines and
I said, I don't understand what's going on with
my money, but I have no money. Like I'm not making
anything. We're bleeding money. Find out what's
going on. And they looked at everything and they're
like, this is the problem. And we started like
fighting it and Blue Cross said too bad. Yeah.
Wow. Wow, wow, wow. How long are your follow
up appointments? 30 minutes. They're always 30
minutes. OK. And what percentage of those do
you think your providers do like brief psychotherapy
with? So like there's like an ethical concern
with that where I like I don't want my providers
going into a 30 minute encounter and being like,
OK, I'm going to, you know, overcharge people
and add in the surprise charge and they're going
to get hit with this feed that they weren't anticipating.
I try to be very transparent in our pricing like
that. If it's like to the insurance company,
like maybe they'll consider doing it. But like
I would say like less than 20 percent. OK. Yeah.
Gotcha. Gotcha. Gotcha. Yeah. Because there's
been places that are like, you're doing 30 minutes.
You have to bill this, which is unethical. No.
No. It's like, did you actually do it? And that's
the thing. And like, these people are going to
get hit with those charges. Or like, you're fraudulently
sending it to insurance, which also isn't great.
Right. It's like, have the conversation with
the person that you're going to be doing this
service and make sure that they're on board with
that. Yeah. And they're actually getting something,
not just like, oh, we have a longer med check.
I'm going to. Throw this in. Yeah. The five in
-person locations you have. Wait, how many of
your providers are like virtual versus like in
person? I think the easier question is how many
in person do we have? We have one in Flagstaff.
We have two in Tucson. We have two in Phoenix.
We have two in Tempe. And we have one in Mesa.
How do you like determine who is like fully virtual
versus in person? Who wants to be in person?
I'm like more like a little bit more on like
I want my newer people coming in to do some in
person. So like I'll make the contract for hybrid,
but also I'll open offices near where they live.
So like I'm not going to expect you to drive
45 minutes to your location. Like I'll just find
a therapy office that's got, you know, a room
open and we'll run it out and you can just do
your work there. Yeah. Okay. As far as like marketing
and where your referrals come from, what's the
like breakdown there? Is it like? I feel like
early on, I probably did so much networking with
like therapists, primary care, everyone I could
find. So midwives, doulas. So I think like a
lot of the people still come from that. And then
we get a lot of like word of mouth of like, you
know, this patient had great care. We're very
much like a very loud, affirming practice. And
I feel like that's beneficial too. So we do see
like a lot of therapists as patients who then
send us their patients too, because they feel
cared for. Yeah. I mean, I'm, I'm a patient.
I mean, it's a good practice. We have great providers.
Right. I mean, what can I say? That's cool though.
That's really cool. Yeah. I think that's kind
of how I even got started was another provider
being like, yeah. Yeah. So that's, I love that.
Your providers that you've found, where have
you found them from primarily? Usually my preference
and like maybe half are students. So if we have
precepted you and we have trained you and we
have verified that you are great at your job
and will be great at your job, then we will hire
on. And then you're kind of already into the
culture. The other ones I feel like I posted
maybe like on Indeed or there was somebody who
found us like, you know, maybe from a TikTok
or something, one of my TikToks, and they submitted
an application from that. But usually like either
an application or a student. OK, how do you decide
what students you'll take? Because I know like
people are very, very thirsty for finding a preceptor.
And it's like, how would one get in the door
at Paper Flower for precepting? Well, you would
read the website and realize what kind of practice
we are and read our story and read our values
and then decide if you align with those values.
And if you do, you would look at the precepting
page and see that I don't want a bullshit cover
letter saying like, hello, I have all of this
experience as an RN and I blah, blah, blah. I
don't care. I don't fucking care about your professionalism.
I don't fucking care about that in a job application.
I want to know who are you as a person. Did you
read my website and do you vibe with that? Like
if you're not writing a personal. personalized
cover letter and a personalized email, I don't
want it. I will literally delete it. Yeah, I
love that. I love that. I think that's really
awesome that you're just like straightforward
about that and direct because I think like, yeah,
there are standards and we need to kind of up
our professionalism, I think. And when we're
looking for those rotations, personally, that's
how I feel. Or down it. You know, for us, it's
down your professionalism and throw, like, a
fuck into your email and, like, I'll probably
respond. Yeah. But, like, it's about catering
it to the. Maybe professionalism isn't the right
term, but, like, intention. Intention. I'll get
messages that are like, hey, Linda, like, on
TikTok or something, like, I need a preceptor,
you know, and I'm just like. And Mariah. Yeah,
I get that, too. And, like, Mariah, I would like
to be at Paper Flowers Psychiatry. And I'm like,
that's cute. Okay. Good luck. Yeah. You're like,
this is not going to be a fit. This is not going
to be a fit. You hired somebody from my fellowship.
That was exciting. God, dude, she is great like
that. This fellowship is so cool because like
when I'm hiring somebody and like they're not
a student with us, like I have no idea if they're
going to suck at their job. Like, what did they
learn? Who did they precept with? Do I need to
teach things? But like she came in so prepared
and you could vouch for her and like she is everything
and more than you vouch for. I love that. I love
her. She's a great provider. She's a great dude.
And that makes me really happy. I love, I kind
of feel like a psych and fee matchmaker a little
bit sometimes where I'm like, I'm kind of about
that. Yeah. You know what I mean? Like who would
be a good fit? And yeah, I enjoy it. So thanks
for giving her a chance. I know she's very grateful
and she's learned a lot. And also like, it was
super cool because when you connected with her
here, she's like been having such a hard time
finding a job in Arizona, which is so different
than when I graduated in 2015. And. She's like,
oh, they're doing like a retreat. And Maria said
I could come. I was like, incredible. Like you
really reinvest into your providers, don't you?
Yeah, that's the thing is like people will underpay
people and like you're not going to have a good
retention rate. I literally don't take a huge
salary from this. We make a ton of money, but
like I will put that into like let's have an
annual retreat. Let's go to Seattle. I'm going
to pay for everybody. Like I'm going to pay for
the hotels. Let's go to Hawaii. Like let me pay
for a boat for everybody to hang out. And like
we get to have these amazing times where we're
bonding for like a week. And that's sick. Like,
why am I going to take a salary? You know, if
I don't. Well, I guess I could need it. But like,
you know, there's better ways to keep people
and have your business going well. Right. Yeah.
And it's like you care about the impact that
you're making on patients, on providers. You
know, you're not just like trying to make money
and go live the high life and be like. I've never
in five, six years of having this, like looked
at a provider and said, you're not making me
enough money. I've never looked at their productivity
numbers, nothing. Like if they can't come into
work because like something happened with their
family, I'll be like, dude, are you okay? Can
I send your refills for you? Do you need anything?
I send them flowers to their house. Like I'll
send them like a love basket. What do they need?
You know? Okay. Yeah, sorry. I'm not laughing
at that. I'm laughing because I remember like,
you know, who you hired from the fellowship calling
me and be like. marie is all concerned about
like my health and she's like so nice i'm like
super tripped out like she cares like i'm super
like thrown off right now just because she didn't
come from an environment like that right yeah
so i just i thought that was really cool she's
like i'm not used to this i'm not i sent her
like i think she got into an accident at one
point and i sent her like just a fender bender
and i sent her like stuff for you know like self
-care stuff so she could take the day off and
just like chill because like that's stressful
you know yeah For sure. Speaking of stress, like
how many patients do you see now these days?
Jeez, man, maybe like I've given up my whole
load. I might have like three left. Three patients?
Yeah, I think that's my caseload right now is
three. I've given up most of them. Yeah, because
it's like I'm sure it's full time running and
scaling a practice like this, right? Like you're
probably. pretty available to like staff cases
and, you know, help the VAs out. Or I don't know,
what does a typical day look like for you? To
be quite honest. I could see patients full time
or at least like part time. I could probably
see them realistically part time and then do
like admin part time. Like my day is typically
like I'll answer urgent things. I'll do on call.
Like if somebody is off on a holiday and there's
a patient in need, I'll see that patient. I'll
do like, you know, somebody can't get in for
an eval and they really need it. I'll do it and
then send them to someone else. Yeah. But usually
it's like I'm there for provider questions. I'm
there to kind of like, you know, put out fires,
answer stuff. But like I mostly don't see patients
because of my kids. Like I'm with my kids so
full time and like I just don't have I don't
have time because of them. If I didn't have my
kids and like when they go to school, I'll be
seeing patients more. Yeah. But right now I just
can't. Yeah. Hundred percent. You also do a lot
of education around autism, neurodivergence.
Yeah. Talk to us about like the Institute, Paperflower
Institute. I know you're going to be coming in
speaking to my fellowship to educate the providers
more on diagnosing that because it's not real
accessible here in Arizona. I know that. And
I think there's like so many misconceptions around
the diagnoses in general and so much stigma from
providers is the problem, because like most of
us, when we were trained back in the day or even
if we were trained now, like we're not getting
the correct information about what this looks
like. Right. Like we have kind of like for people
who don't understand it, like you kind of come
into this like what does autism look like? It
looks like somebody who's like flapping their
hands. It looks like a little boy who loves trains.
Right. Like I don't. probably present as autistic
to most people who are going to look at me. I
am autistic. My kids are autistic. And they wouldn't
have like, you know, scored as autistic on the
gold standard, the ADOS. Like they failed that
technically. So like. When people are on like
the PMHNP board saying like, oh, what's wrong
with this person? I think it's a personality
disorder. It's access to and like I'm reading
it and I'm like, they're fucking autistic. Like,
why is nobody asking about that as the differential?
Like, you guys are not like looking at so many
like missing components of like, what can autism
present as? So I've been trying to like advocate
more for my providers, my team, like let's implement
sensory screenings on every single new patient
we have. Like, sure, you have a PHQ -9, you have
a GAD, but why not send a sensory screener? And
then you can see like, are they answering? these
questions too literally their sensory screener
is really high like it's a possibility of neurodivergence
right so we're not misdiagnosing people so very
much like focused on that yeah because i remember
early on where i was working them being like
well you know in arizona like it's not recognized
for psych mps to diagnose this so basically you
know don't diagnose it because you're not going
to be able to treat it and try to just refer
out and i'm like okay to who like But that's
the right. And there's not a lot of providers
who do. But we can diagnose it if you feel competent.
We just don't have that accepted by DDD. However,
there are a large amount of people now looking
for answers for a late diagnosis of why am I
so different? What's wrong with me? Like, am
I autistic? And like you have these providers
who are throwing them back saying, well, you
make eye contact. You can't be autistic. Like,
why are you here? These people have done hours
and weeks of research before presenting to your
office and probably very much are autistic. Right.
So like we can prevent like we can go ahead and
like give validating diagnoses. We do that. I
do that. That's good to know, though, because
I've had patients who come to me who have been
like, I paid a couple thousand dollars for this
diagnosis, you know, at this place in New York
because I didn't really know where to go for
that. So they can they can, you know, come to
Paper Flower and get that type of treatment and
help. We do like long neurodivergence evals.
I'll send out like a 30 page report with like
recommendations for OT and sensory stuff. And
we talk about like, what does it look like to
be late diagnosed? I'm late diagnosed. I wasn't
diagnosed until like two years ago. And then
can you talk about Leucovorin? Is that how you
say it? I think so. That's how I've been saying
it. This is a medication that was recently kind
of like. spoken about loudly by our government
saying like, this could be the cure for autism.
This is not in fact a cure for autism. However,
this is a very beneficial medication that's been
around for like a decade. People have been using
this medication for quite a long time. This is
actually a high dose of folic acid, right? So
there's different forms of folate. It's very
complicated when you look at it. I actually made
a a course too on paper flower institute of how
to prescribe it how to kind of like anticipate
side effects dosing all that stuff because it's
not in like stall right but essentially like
people find anecdotal benefits so if you're looking
at reddit versus like you know evidence -based
shit that like nobody's done the study yet you'll
find that people are like my non -verbal child
is speaking like personally i put my kids on
it and i saw insane benefits wow that's incredible
so How is it different than like L -methylfolate?
That's a good question. So like L -methylfolate
is like a already processed form of folate that
kind of goes into the brain and it does one job,
right? It just has one job. Folinic acid, which
is leucovorin, is like kind of the truck of supplies.
It's like all of the types of folate and it can
morph into anything. Passes the blood -brain
barrier, like, very easily and can, like, spread
and kind of restore things. Interesting. So it
works a lot differently. There's, like, some
thought that, like, up to 60 % of autistic people
might be deficient in folinic acid. Gotcha. So
you've had a lot of success with this, sounds
like. Yes. With your paychecks, too. Yes. For
sure. Cool. I gotta get my... fellowship people
access to your course somehow we'll talk about
that later good discount I got you because it's
like they they've asked about it right and to
your point it's like evidence -based versus like
reddit like yeah it is hard sometimes you know
being on like more the teaching front as far
as like yeah like oritate lithium oritate you
know I've been doing that and I feel like it's
helpful but it's like yeah it's kind of like
you know Big wellness is making a lot of money,
too. Right. So it's like trying to be judicious
when looking at these types of interventions.
You know what I mean? Because patients will come
and ask. So because they're hearing it with their
on social media, Reddit, like it's like same
thing with like even, you know, micro tapers
and deprescribing and like. And people are seeking
me out for that because they're like, we can't
afford like Dr. Whatever's paper clinic. And
we thought, you know, but will you work with
me in a compounding pharmacy? And I'm like, yeah,
sure. Yeah, I'll do that. That's like a huge
thing. And for people who don't know about that,
it's a really important topic, right? Because
if you've never withdrawn from antidepressants
before, it's quite uncomfortable. So if there's
a solution, there's a solution. Yeah, 100%. I
agree. How do you take care of your mental health
with like balancing these like three branches
of paper flower and having two kids? Like how
do you? I don't think that there's a great answer
for me because I feel like I'm constantly drowning,
but I have my own therapist. I try to like do
some time like I have a respite provider now
for my kids for a few hours a week. And that's
been like insanely helpful. So even when they're
at preschool, I'm trying to take advantage of
like, OK, I'm going to work for a couple hours.
I'm going to do something for myself. For me,
it's like I'm going to take my dogs for a walk
and I'm going to tattoo myself. That's all I
want to do. You know, it's just zone out. You
tattoo yourself? I do. Yeah. I got a little tattoo
setup kit over here. What? I had no idea. I'm
working on my knees today. Wow. I had no idea.
That's just impressive. It's new. It's new. It's
our paper flower hobby for a few of us. We just
tattoo ourselves and autistically talk about
it on text of, what did you tattoo yourself today?
And when we get together, we tattoo each other
quietly. That is hilarious. Why did I not know
this about you? It's a fun fact. Yeah, it is
a fun fact. We got into all the logistics. We
didn't even really get to talk about you just
on a personal level. Where were you born and
raised? Do you have siblings? Massachusetts.
I was born in rural Berkshires, the mountains.
There's not much there. There's really no hope
for life there. I was only able to go to nursing
school because I got a scholarship from the nurse
corps. So they paid for me to go to school. Otherwise,
I would have been probably still in Pittsfield
watching people die from heroin overdoses. Gotcha.
So pretty bleak. Pretty bleak, pretty sad place.
Like, yeah, it's just not a good place. And I
don't really have much contact with my family
anymore. Just kind of like everything's here.
Everything's Arizona for me. When did you move
to Arizona? 2017. I got divorced in 2016. I said,
I'm leaving here. I'm never coming back to this
place. And I just applied all over the country.
Arizona gave me a job and said they'd pay for
me to move. So I said, OK, here I go. And me
and my cat moved. Wow. I didn't realize that
you moved to Arizona in 2016. Yeah. Yeah. Right
after I graduated. When did you graduate psych
NP school? It was 2017. So 2017, I graduated
and I just left like that week. I left. Where
did you go for your DNP? I went to UMass Amherst
for my DNP online, but then it was just a great
program. I really loved it. Oh, that's cool.
And then Regis College back in the day in like
2014 for nursing school and psych NP school.
Okay. Okay. Gotcha. It was in person back then.
Would you recommend that program? I don't know.
Like 10 years ago, I would say, yeah, I don't
know about it now, but you know, it was a great,
I worked as a professor at ASU and their nursing
program is a great program too. I can say that.
Yeah. What do you think about the influx of people
becoming psych NPs? Like, like, you know, the
pandemic hit virtual stuff. Like, I mean, surely
you've noticed like a difference. from when we
were first starting out right to like now like
what do you think about all of it because it's
it's a lot it's really fucking scary for the
people who are going out there blind after 600
hours of clinical and like your clinicals are
varied I've had multiple people I've hired through
my practice that I've had to terminate because
they were poor providers that like they must
have learned we were like beyond level one in
nursing school like I couldn't even we couldn't
catch up I'm very much a mentor but like the
like the fact that they passed boards was terrifying
to me like medication errors not knowing dosing
not knowing side effects like very basic things
and not knowing anything they're graduating like
this and passing the boards there are people
like it's all about like what you put into it
and there's people who graduate from Walden and
Frontier and these accelerated programs and they
can be phenomenal because they put the extra
work into it but then there's people who just
don't give a fuck and they want to make money
and that's terrifying It really is. So you've
seen like this difference in the quality of.
Yes. And like I am very much like the person
of like, let's do this is kind of like a fellowship
new job and we'll kind of ease you in. And like,
dude, like sometimes there's no hope. Like there's
just no hope. It's so scary. So, I mean, I appreciate
your like fellowship program because like, dude,
if without that, like people would be lost. So
it kind of like adds that extra oomph of like
here you're going to walk into a job and actually
not be scared. Yeah. Because it has been a drastic
change that I've noticed, too, where I'm just
like, this is a serious job. Like, I mean, sure,
you can have fun. You don't have to be a super
serious person. You don't have to be super professional.
But, like, we're impacting people's lives. Like,
take it seriously, you guys. You could kill people.
Like, you can very much kill people. And although
they have not yet, like. like I've seen providers
we've had patients in my practice die right from
like all sorts of things suicides or whatever
and like that happens and I don't know if these
people are unaware like you think you're just
gonna make a bunch of money in psych like this
shit's wild yeah no 100 100 what would you say
like brings you the most impact with what you're
doing now in your career versus like what's been
like The hardest part. The most impact I feel
like has been sticking by my ethics. And I feel
like that has brought me to wonderful places
and it has kept me retention and it has grown
this and it has had like, you know, patients
come because there's like authenticity and I'm
staying with my ethics. And I feel like that
has been like a saving grace is not selling out.
The hardest thing, dude, I don't know. I feel
like as like a boss, like firing people fucking
sucks. I feel like. like insurance is hard like
there's just so many like HIPAA is hard we had
a HIPAA violation had to get lawyers involved
and like when you move into a big practice like
there are so many like it just sucks I didn't
come in to be an administrator I'm only the administrator
and have a big practice because I got kids like
and I can't see patients yeah so I feel like
that whole part is just awful for me yeah I can't
imagine like yeah having to fire but yeah I mean
I have had to do it before but it's not fun you
know It's like, yeah, but I can see where it's
necessary, you know? So your husband's a nurse.
Yeah, he is. What does he think about this whole,
I don't even know what to call it, empire you've
built? It's hilarious because I don't think he
thinks anything. He didn't even, like, believe
I had followers on TikTok for the longest time.
I'm like, look, it's over 100 ,000. And he's
like. Uh -huh. You know, he's like so apathetic
about everything. I had him like try to help
me in the early days, like make phone calls.
And he was just like not into helping. That's
why I'm like people have husbands who help them.
That's amazing. Mine gives no fucks. He literally
doesn't say anything. I don't know. Maybe it's
his autism. Like, do you see what I built? Yeah.
I'm like, I'm proud of myself. Look at it. Look
at this nonprofit. I mean, he's like, cool. Okay.
Go play with your Legos. Like, I don't know.
It actually is kind of it's crazy to think about,
like when we first connected back in 2020 to
now, like all the different things that you felt.
It blows my mind sometimes when I like sit down
and look at it because like, I don't know, on
the day to day, I'm just exhausted and drowning
and there's just so much to do. But like it did
take off and it is it's its own thing. And, you
know, our practices paved the way for a lot of
similar practices to also be vocal. So that's
been cool. Yeah. Have you gotten a lot of that
feedback from other providers? Oh, we're allowed
to speak out and be authentically us and not
be professional. I've had like quite a few people
who say like our practice is the way it is because
of yours. So that was cool, you know, to feel
like I did something special. Yeah, 100 % and
actually make a difference in the provider's
lives who are helping patients like there's that
ripple effect, which is why I'm guessing. would
you ever sell paper flower? No, no. I knew the
answer to that. I just wanted to, you know, it's
funny, like funny story. So like our first retreat
ever, Bree, who's like one of my first providers
I hired, she's like, Maria, someday this is going
to get so big that someone's going to offer you
$2 million. And I just want you to know when
you take that, just like, tell me, you have to
tell me so I can leave and make my own practice.
And I'll just hire everybody. And I was like,
why would you think I would accept it? And she
was like, because you're going to take two million
dollars. I've been offered millions for my practice
and I will not take it. I have. Have you been?
Have you been? I have been like millions. By
random. Random investors or companies that wanted
to buy out and move here because we're very established.
And I said no, because like all my VAs would
lose their jobs. They'd have nowhere to go. They'd
have nowhere to support themselves. No one's
going to pay them this much. Right. Like it's
my baby. Yeah. And it's like also like. I get
the impression your like sense of purpose, sense
of identity. Like, you know, I think about that
too. Like, I'm like, I love doing what I do every
day. Yeah. You know, if I didn't have that, I'd
probably not be doing well mentally. Like I can
do that. Like kind of, yeah, it's a huge part
of who I am. Yeah. I love my company. Like this
is my baby and I built this and like, I don't
want to watch somebody just trash it. Yeah. And
I think that's reassuring for providers who go
to work for you too, though, because that's why
I left my last job. They got acquired and I was
like, uh, hi, you know, and that was the right
decision because it's completely changed the
culture, everything, you know, it's like, I don't
know. Yeah. Things have changed a lot with telehealth
and the pandemic and venture capital and it's,
yeah. All those places now that people are moving
into and like. You know, there's just so many
like corporations, I think, preying on providers.
Yeah. Speaking of which, like how do you feel
about newer providers working for themselves?
In the way of like making their own LLC or the
way of like just gotten on headway or what do
you mean? Like, yeah, building a private practice
because that's like one of the number one asked
questions. Oh, like out of school, like straight
out of school? Yes. Scary? For me, learning to
run a practice was its own thing. Never mind,
you're going to be learning coding, you're going
to be learning credentialing, you're going to
be learning how to prescribe and you have no
one to ask or resources. That shit's crazy. I
feel like you should find a job with a mentor
and build in. Actually, I didn't have that. I
went home and I got drunk and cried myself to
sleep and read textbooks every night until I
felt competent. And, like, that was my, like,
mission in coming here and training my providers
and saying no one should have to do that as a
new graduate. But also, who's going to, like,
voluntarily choose that? That fucking sucked.
I didn't know anything. Yeah, right. You know?
100%. Yeah, I can't imagine opening a private
practice where I was at as a new grad, you know?
No. No. Like, that's ballsy. That's really ballsy.
That's what I needed to learn, you know? Yeah.
So. I'm not saying it's not like possible and
people are doing it and outsourcing their mentorship.
And, you know, that's great just for me. Like,
I can't imagine my anxiety levels. Same girl.
Same. Like, would have regretted that hard. Like,
I only was able to do this because I had so much
experience and like hire people in because like,
hey, I have experience. I can help you. Like,
we can support you. Like, imagine like having
a private practice and you've just been a new
grad and then hiring people like you can't even
offer them anything. You're all lost. Right.
And then the clinical decisions, you know, and
like I'm sure how like are you putting out fires
a lot with like patient situations? Yeah. Yeah.
All the time. Right. All the time. All the time.
Yeah. All the time. So like that's exhausting.
Like, you know, you have like things come up
on holidays. Like, do you have plans for that?
Like, do you know all of the scientifics that
could happen? Like, can you anticipate like what
this is going to look like? Like, I don't. Maybe
if you take the most stable people ever who are
going to be on like Lexapro 2 .5 forever. Sure.
Open a private practice. But like you don't know
what's coming in your door. Yeah. No, 100 percent.
100 percent. What would you recommend to a new
grad psych NP as far as just like. main advice?
My main advice would be to take initiative for
yourself. Your school has failed you already
by graduating you, no matter where you come from.
I was also failed coming from a very like intense
program. Like you don't know anything coming
out of 600 hours. So find resources and immerse
yourself. You should be like studying after you
pass sports. You should be like doing a program
like yours. I read, I bought textbooks. for psychiatrists
i bet like sleep textbooks i've got everything
i could do and i like read all of those textbooks
and i studied for like two years after i graduated
to continue learning like you know nothing graduating
so my main advice is like continue learning because
we even like years in like dude i don't know
anything like don't pretend you know everything
that's my advice That's good advice, honestly.
Yeah. It's like have some intellectual humility
to realize that like we don't know a lot in this
field as much as we would like to know. So yeah,
let's be humble about that. Minus out the clinical
experience out of that because we don't get enough
in school. I mean, like that's yeah. Speaking
of which, how are your clinicals? Fantastic.
Fucking fantastic. I love my clinicals. My first
one was actually awful because like she was super
on a different value system. Trump had just won.
She was very Trump. She was very money, very
private practice, had people pill mill style
coming in and out like I just didn't. respect
her and her like decisions were awful. But my
next one, I was at UMass Memorial and like the
most phenomenal preceptor I could have ever asked
for. And she taught me about autism and ADHD
and she taught me about like child mental health.
And she got me into every opportunity to be with
psychiatrists or like social workers or anywhere
in the hospital that I could learn. Like she
was incredible. Wow. That's incredible. And your
school placed you for those? Yeah. Both of them.
Yeah. like that's another thing I worry about
is just like the clinical experiences that people
are getting where they're like paying for these
experiences where there's multiple people on
a call and they're not, I would not suggest people
do that because it's like, like find a good rotation
where you're going to learn. You're going to
be able to like ask questions. Like I had to
interview for some of my rotations. I did too.
You did? Yeah. I interviewed. I didn't know that.
Yeah. Now like, like people who come to you.
Absolutely. Yeah. Yeah. I'll never take people
blind. We have to interview them first or we
have to like know them first or talk to them
first. Have a good sense. Yeah. A hundred percent.
That's crazy. And like some of this, like if
you're not doing the evaluations independently
and making the medication decisions and education
independently by the end, you are not prepared.
And I've had people who've never asked a single
question to a patient graduate. Like that was
like. I did all of my own evaluations. Like my
preceptor gave me two days before I was doing
them. And that's how I've always precepted people
too. You get two days to watch me and then you're
doing it. Jump in. Right. Yeah. No, a hundred
percent. And then can you imagine the transition
from, if you hadn't, like, I'm just like, I know
it's, it floors me. It floors me. Like you don't
even have a template. You don't have anything.
Oh my God. Yeah. It's not good. What are your
favorite resources that you encourage your employees
to use and like would encourage other psych NPs
to use? I've made a lot of resources because
like I don't like the resources that are out
there. I don't like stall very much. So I've
like made a lot for them when I think about it.
But I do like the perinatal mental health one
postpartum .net is amazing. Like their training.
I have all my providers do it. I love that. The
PSI? PSI. Okay. That's cool to have all your
providers. I love that. I love that. Because
I remember that like you and I, I think we did
like a live together and like just like realizing
like, wow, I need a lot more training in this
area. And I was a mom who was pregnant and a
psych provider. And why didn't I know this kind
of stuff? Yeah. Yeah. I remember that. And like
there were not a lot of people trained back in
like 2018 when I did it, but there's a lot more
people now who are. That's cool. So common. Yeah.
But that's probably like the biggest one that
I'm like, this is amazing. And then just finding
like ways to learn about neurodivergence and
like, honestly, Reddit, like start reading Reddits
and understanding people. And like, yeah, that's
the biggest thing, dude. Yeah. And then I would
say your program is also big, like for people
who are graduating with nothing, like go to the
program. Yeah. Get your contact hour, 75 contact
hours. Do it. Yeah. That's really cool, though,
that you pay for people to do the PSI training
because I really feel like everybody should.
Everyone should do it. I mean, like your patients
get pregnant all the time, right? Like somebody's
going to be pregnant. Somebody's going to be
postpartum. Like somebody already has kids and
experienced something. It's just so important.
Yeah. How much of a difference do you feel like
our medications make? Like how much of your practice
is like also like lifestyle education? I would
say it's like integrated into most appointments.
Like everybody's trying to kind of look at that
too. Maybe like, but I mean, medication is still
like the biggest focus for it. Yeah, I don't
know. I would say it's kind of like 50 -50 implementing.
Like everybody's kind of like we do 90 minute
evaluations. We really get to know a person and
kind of like have those conversations to like
what's going on with sleep hygiene, what's going
on with like X, Y and Z. Like what else? But
I mean, a good provider is probably going to
do like 40 percent of like what's the environmental
situation? You know, like how is this being impacted
by the medication and what's not related and
what is related? Where are the patterns? Yeah.
Addressing that. Right. Yeah. It's important.
I know we're going on like an hour and I try
to keep these episodes like 20 or 30 minutes,
but it's like, I knew that we would have like
a ton to cover and I still feel like we didn't
even get to cover everything. Okay. One, two
last questions. AI, how do you use it right now
in your practice? My practitioners use Heidi.
I think that's what it's called for documentation.
I personally am too old for that now. I feel
like I just have to type everything and that's
always how I do my evaluations. I can't get into
it. I'm like, no, I don't want it to type for
me. I want to type. It's like an old lady saying
that. It's so embarrassing. Everyone else does
it. I'm like, okay. I've been typing for 10 years.
I just want to type. So tools I use, I use Claude.
Is that how you say it? cloud clod and i use
it just for administrative things like letter
writing kind of like understanding ethics like
understanding just anything all i just my whole
life is on that yeah like you're like a yeah
i'm a clod girl too now i love love out there
dude they have the best i love the work did you
check out co -work no i haven't done it yet i
have to make a note because i forgot don't talk
to me on my adderall that's why it'll change
your life you're gonna you're gonna love it And
then what does the phrase no prior auth mean
to you? I ask all the people who come on this
podcast that at the end. Oh, I wish I had prepared
that. No prior auth would mean no bureaucratic
restrictions when I think of that. Yeah, which
I feel like is your entire like being. My being.
It's my essence. It's your essence. That was
the word I was looking for. Yeah, which I think
people are inspired by. Like, I mean, you're
brave. You're not afraid to get criticized or,
you know, get you're like, I am who I am. Take
it or leave it. Yeah, it gets me in trouble.
I'll, you know, have my pile of cease and desist
for being loud and obnoxious. So I'll just really
those quietly. Yeah, I don't even know if I'm
allowed to talk. about it but you know i have
my my liberal opinions and have i called people
out for practices that i found unethical sure
have i gotten cease and desist from their lawyers
sure yeah that you're like i'm not gonna let
like people's fear base at the end of the day
like i'm living authentically and my practice
is authentic you do you if you want to have an
inauthentic practice that's on yourself you know
yeah just kind of taking responsibility for yourself
and for the practice you're growing and that's
that period the end your airport i love that
where can people find you if they want to follow
along and get involved in some of these initiatives
if you want to follow me on tiktok dr .maria
and gala And my foundation is paperflowerfoundation
.org. I would ask you, even if you're not in
Arizona, please make a donation, just like 20
bucks, something just so we can like continue
our work. Paperflower Psychiatry, if you want
to work for me and you are super liberal, I will
hire you if you don't suck at your job and you
can't be professional. If you don't suck at your
job. Yeah. And you can't suck at your job. That's
me. Yep. I love it. Okay. What about if providers
want to take your courses? Oh, paperflowerinstitute
.com. So paperflowerinstitute .com. I have a
lot of free educational resources, even learn
more about autism, learn about neurodivergence.
Like there are a lot of things that you can give
to patients on there too and refer your patients
to that website. You can also take continuing
education courses. They are accredited. So you
can take those courses. Yeah. And your podcast.
Like I hadn't really listened to your podcast
until like the other day. And I was like learning
a lot about like, it was like something with
autism. And I was like, wow. Yeah. Brain Trash
is on Apple podcasts on YouTube and Tabitha is
like super brilliant. She talks a lot about neurodivergence
too. It's just two of us autistic folks with
no filter talking about. That's the whole podcast.
That's cool. Yeah. About autism, about neurodivergence,
about why the DSM sucks. Yeah. How do you, how
many episodes do you have out? We have like two
seasons, dude. It's like a solid amount, maybe
like 20 or something. And Tabitha is one of your
providers? Yeah, Tabitha is a provider. She's
my homie. I love Tabitha. That's awesome. I love
that. Well, thank you, Maria, for taking the
time to be here. We love your heart. We love
your mission, what you're doing. We're going
to have you on for a part two because I know
people are going to have questions, additional
questions, because you do things outside the
lines. Sure do. I'm ready for questions. So leave
them for Lindsay and we can do a part two. Okay,
awesome. Thanks for being here. Thank you so
much.