Digital Marketing with Ryan Miller

November 10, 2021

The medical industry has many regulations, including how you can market your practice. In this episode we are joined by Ryan Miller, CEO of Etna Interactive and thought leader in the digital marketing space. Join us as we zoom in on the future of digital marketing, marketing budgets for your medical practice, and legal compliance considerations for medical advertising.

Listen to the full episode using the player below, or by visiting one of the links below. Below is the episode’s transcript which has been edited for readability. If you have any questions or would like to learn more, email us at


Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto. Legal issues, simplified through real client stories and real world experiences. Creating simplicity in three, two, one.

Brad: Welcome back to another episode of the Legal 123s with ByrdAdatto. I’m your host Brad Adatto with my cohost Michael Byrd

Michael: As a business and healthcare law firm, details matter. This season’s theme is zoom in. Once we know our big picture vision strategy, we have to roll up our sleeves to get the work done. With each episode this season we’ll have our typical stories and make sure we talk about specific actions to focus on for 2022.

Brad: Michael, I’m really excited for today’s guest because I think we’ve known this guest longer than anyone else we’ve ever had on our show.

Michael: It’s definitely close. I mean, I think we go back close to 15 years or so, but Brad, before we start, I forgot to tell you about a crazy story from one of our Access+ [00:01:00] clients last week.

Brad: Okay. I am bracing myself. What did you do?

Michael: Well, that’s not me this time. Fair question. This is really more about the crazy times we live in. Our client has a restaurant concept. He and his wife opened store number one in the fall of 2019 in California and we’re crushing it. They had no idea that less than six months into it they’d be shut down by COVID.

Brad: Yeah. And I actually unfortunately know this story and I remember they were able to survive and no small thanks to the part that they got the PPP loans to keep things open.

Michael: I thought we had a deal that we weren’t going to say the word PPP.

Brad: Yeah. I kind of got shivers as I said it.

Michael: There’s a new second part to the story. Our client opened restaurant number two in Tahoe in July and actually just crushed it again in their first month [00:02:00] until they were closed by because of the Caldor fire.

Brad: Oh, that’s brutal.

Michael: Yeah, no doubt. He had gone silent for a month or so, and he was able to laugh a little bit because he was back open again and things were starting to be on the uptick. And I think he figured all of his natural disasters were over. But speaking of, how’s your family doing in New Orleans after Hurricane Ida?

Brad: They’re actually good. Thanks for asking. Luckily for them they didn’t have any major damages to their homes, except for the two and a half weeks of no power, which they left to go stay with family members, otherwise they were good.

Michael: Okay. Good. There have been so many natural disasters it feels like every time you open up the news or something. Have you heard about the La Palma volcano in the Canary Islands?

Brad: Yes, I am a news junkie, as you probably know [00:03:00] and I did see some videos of people being evacuated, a bunch of buildings on fire.

Michael: Yeah. I think over a thousand buildings have been destroyed. When I was looking up the latest on this volcano, I stumbled across an interesting stat. Do you know how many active volcanoes there are right now?

Brad: 1 billion.

Michael: That’s a little aggressive, Brad.

Brad: Sorry.

Michael: I like where your head is. Okay yeah, but no, there’s 50.

Brad: Well, our guest is still with us. Hopefully he hasn’t hung up since he’s known us long enough. So enlighten me how volcano talk and natural disaster talk brings in today’s guest.

Michael: I’m glad you asked. Our client’s company, Etna Interactive is named after the Etna volcano in Italy and it is one of the 50 currently active volcanoes. And as a bonus, our guest’s home office is in California, just like our Access+ client with the [00:04:00] restaurant.

Bad: Well played Michael, very impressed with you. You probably should give Siri a bonus or maybe some time off with all this intense research.

Michael: Hey deep research skills over here. Well, let me introduce today’s guest. Joining us today is Ryan Miller. He’s the founder and CEO of Etna Interactive. Ryan went to California Polytechnic State University. He founded at Etna Interactive in 2002. Etna provides digital marketing services including SEO, social media management, reputation management, content marketing, and digital advertising. We’ve known Ryan for many years, as we’ve talked about. Ryan lectures around the country at medical conferences and is definitely a thought leader in this space, Ryan welcome.

Ryan: Great to be here, gentlemen. Thank you.

Brad: Well Ryan, as Michael was saying, we go way back. So we’re excited to have you join us today for the show and [00:05:00] first, obviously we had a little volcano talk here, but tell us what made you decide to name your company after the Italian volcano?

Ryan: Yeah. So coming up on 20 years ago now, I was put in a position where at that particular time I was working for one of the first roll-ups in plastic surgery, coming home, the plastic surgery company. We had a stake in about 32 plastic surgery practices around the United States and where the company was originally when I was recruited, headquartered in Santa Barbara, California, just a little bit south of where my home is. They were moving to Atlanta and my wife, my family, everything was out here in California and I knew that I didn’t really want to move. So I was faced with the decision about what to do. I happened to be on a holiday sailing around Italy, stopped off in Sicily and went for a hike up Mount Etna to traveling with a group of friends. And I said, you know what guys I need some time to myself. Why don’t you guys keep hiking? I’m going to go off on this other trail and have a few moments of reflection. [00:06:00] And it was actually freezing in the middle of the summer on top of the mountain, but I kind of hovered down inside a little volcanic vent that was blowing up warm air and standing on this incredible black landscape and realizing as I had been talking to my guide moments before that what I was staring at was the melted and mangled remains of a ski lift that was this like intrinsic, dynamic, transformative landscape. And I said, you know what? I think I’m ready to do it again. It was my second startup. I think I’m ready to start a company. I’m not going to go to Atlanta. I’m going to pitch my employer on becoming my first client. And I’m going to start a consultancy that focuses on online marketing for electric healthcare. So there you go. That’s the connection to Mount Etna. That was the moment in the day, that’s where I was when I decided to start the company.

Brad: Michael, that’s a little bit better in our story when we started the firm, because ours was in a tex-mex restaurant. So yours is much better. I like that idea better. [00:07:00]

Michael: However, it was in the same restaurant where Jimmy Johnson and Jerry Jones were famously caught striking a deal for Jimmy Johnson to become the coach of the Dallas Cowboys.

Brad: True. True.

Michael: But that’s more local, I guess. Well, that’s awesome and we could feel the energy as we call ourselves entrepreneurs, trapped in lawyers’ bodies. And so having gone through finally a little bit later in life, the experience of starting a firm, we could feel the energy. Talk to us a little bit more about what things were like in the beginning when you started. And I guess you got this first client that was your former employer.

Ryan: We couldn’t have been more fortunate than to start off on day one with a book of 32 really deeply engaged and loyal [00:08:00] clients. Many of whom are actually still clients today, 20 years later. And you know, talk about a warm start. Yeah, it was a great place to be. Many of those clients were shaping the perception of marketing in the industry at that time. Probably the best known of which was Dr. Grant Stevens. And it was great to kind of grow up alongside him as his own marketing perspective marketing was maturing and it gave us the opportunity to build and attract new business inside of the plastic surgery space before we’ve grown to where we are today, we serve 11 different clinical specialties all over North America. So, you know, very different. You know, a small group of us back in the day for the first few years, we actually operated out of my house because the office I had been working in an up and moved to Atlanta. And today we’re a team of 75. I used to be able to say, we all operated out of the same office in San Luis Obispo, California, but thanks to the pandemic we’ve gone remote [00:09:00] first and now we’ve got team members that have largely come back to their roots where their families were and got team members in seven different states.

Michael: Wow. Well, as you were talking, it just reminded me that Brad and I have been practicing as long as you’ve had this business open. The marketing landscape in plastic surgery is way different today than it was back then. And how challenging was that for you to kind of overcome or deal with the resistance that doctors had about advertising for medical services or marketing for medical services?

Ryan: I remember in the very, very early days, the first time I was ever invited to speak in an industry meeting I had somebody pull me aside before I went on stage and tell me, I can’t use the words marketing sales or conversion, or I wouldn’t be booed off stage. I had a moment, like, what do I say around came up with patient attraction, that’s going to work. When I talk about marketing I can talk about communications. And sales, okay, that’s going to be our consultation, and it was a very strong education early on. I was in a space that was at once not ready for what I had to say, but also was deeply in need of it because at that same time guys, we work with only core practices. So board certified plastic surgeons, facial plastic surgeons, board-certified with specialty training and board certified dermatologists who were practicing in their own lane. And what we saw then something we still see today is that non-core physicians were basically eating the plastic of surgeon’s lunch. They’re just coming in and grabbing that market share away. And it [00:11:00] wasn’t until, as a specialty that there was an acceptance of outbound communication on behalf of core doctors that we start to see the ability for them to compete against the non-core to earn the opportunity to consult with the patients decide, you know, are we a good fit for each other?

Brad: I want to ask one more question before we move forward to actually what your business does. When you’re talking to a potential client, are we giving a speech are you telling someone, hey, look, this is what the market is bearing right now. As far as when you’re looking at your net revenue, this is how much you should allocate towards the digital marketing side of your marketing. How do you have those conversations, or do you hear that just in the industry in general?

Ryan: We could ask the conversation it’s a question guys where I feel like, hey, I’ve kind of, I’ve got a conflict of interest. I sell the services that will be funded by that budget allocation. So I tend to write [00:12:00] towards other consultants who are on the operation side, who can objectively like Terri Ross is someone I respect a lot, we crossed paths a lot, especially in the medical spa arena, and she recently published a post I thought was really well said that if you are an established practice, you’re going to spend probably sub 2% of your total budget on marketing activities. If you are in the middle of the lane and you’re in moderate growth mode, you’re going to spend somewhere in the 5% to 10% range. If you’re brand new and you’re starting up a practice, you may be spending close to 20% of your revenues on marketing. And so lifecycle is a big part of that. We approach it differently and the work that we do, we do a strategy first approach. We sit down and we name specific business goals, whether it’s a number of new patients for specific procedures, growth of a particular asset. We identify those things. We put the plan together and then we put a price on the plan and together with our clients we sit down and say, [00:13:00] does it make sense for you to spend this to meet this goal. And in most cases we can actually be predictive in our return on investment. And so it’s less about a percentage of revenue and instead an investment in a specific set of activities to achieve a very specific business outcome.

Brad: Yeah. All good points. I think for our audience, who’s hearing this for the first time or considering it, and everything you just said we’ve heard the same thing in the industry, but it’s good to hear that we’re hearing the same thing over and over again, but let’s jump into what exactly does Etna Interactive provide?

Ryan: Yeah, so we’re a full service digital marketing consultancy and we do everything from a website design to content marketing, search engine optimization, local optimization. We do a tremendous amount of work in paid advertising. Both paid search advertising and paid social media advertising. We ghost write for our clients, we do email marketing, manage large scale e-commerce [00:14:00] for our clients who’ve moved to direct online sales as a model for how they support their business. I think of all of that stuff that I think probably the most dynamic service that we provide is that strategy moment. That moment, where we can sit one-to-one with clinic leadership and say, what do we have to do to get you to the next place you want your business to be?

Michael: That’s awesome. And maybe, it is the strategy area, but I’m curious at the risk of using an overused term, if you know what you would call it kind of your superpower or sweet spot, or maybe just Etna’s sweet spot.

Ryan: I would say for me personally, its synthesis and my special gift in this lifetime is the ability to take a bunch of different input and really quickly assemble it to something meaningful. I think that’s a part of what I’ve hoped to bake into our company culture is the ability to go out and stay curious, [00:15:00] dig from our clients, things that other agencies that are focused on different aspects of marketing overlook. Find out both what’s special about them and then the special vision that they have for where they want to take their practice and then bake that together into a really specific plan where we can partner over the long haul to help them build that perfect practice for their perfect practice.

Brad: I’m assuming being the founder of this entity, it helps to be able to do that too because not just helping your clients build their practice, obviously you’ve grown since 2002 with 75 people having that superpower that you said to me to take all this information and break it down, it’s pretty important. Even when you put your CEO, CFO, whatever hat you’re going to want to wear that day.

Ryan: Absolutely. I think that special skill, that special ability is intensely valuable in the online space because it is, well going back to the volcano, [00:16:00] it’s so dynamic. The landscape is completely changed on almost a daily basis and at our size being able to pivot quickly when the environment has thrown something new at us has been something that’s allowed us to stay in a strong leadership position now for all.

Brad: And that’s a great segue to my next question. It’s almost as if you could read my mind. There was a big pivot that happened in 2020 and so talk to our audience about what shifts that you had to do with in light of COVID for your clientele.

Ryan: So our initial response in that period with all of the uncertainty, when we had clients who could not see patients, you know, we enacted what were called branches. We paused all marketing activities where we paused selective marketing activities to right-size what we were doing for where our clients were super interesting. If we think about those phases, that was fairly short lived for most of them, it was under 60 days before everybody was able to pull [00:17:00] back, realize this wasn’t going away and shift into this aggressive mode of outward communication and adaptation. And in some ways I’m a little bit saddened that it, that second phase was as short as it was, like two to four months later we were as an industry in elective healthcare busier than we’ve ever been, in almost every specialty that we were serving. And so I think some of those lessons that were baked into that two months, three to four month period after the initial closures were quickly overlooked or let go because everybody sort of shifted into a feast mode where it’s this platter of new patient opportunity that’s sitting in front of us. What do we do to take advantage of that? And I’m actually really excited for what comes next, right? Where we’re going to stay busy for the foreseeable future. But you know, this level of busy-ness can’t live [00:18:00] on forever because we all have this beautiful moment of learning that happened right in the middle of 2020 to go back and say, okay, wait a minute. How did we adapt in that moment? And which of those things that we quickly set aside are worth bringing back out of the cupboard to help us when eventually things get a little tougher again.

Michael: That’s awesome. That’s really cool. So the theme, as you may have heard at the beginning for the season is zoom in and we would love for you to just kind of share some thoughts on some things surgeons can focus on for 2022.

Ryan: Yeah. So I think probably the first one that comes out from you guys is the idea of marketing automation. So we saw some early embrace of marketing automation technologies right in the midst of COVID. We saw more move towards virtualization, like virtual consults because it was all we could do. E-commerce because we could sell skincare where we couldn’t treat patients [00:19:00] over in the aesthetic side of things. We saw more integrated medicine platforms being adopted because guess where the people were that were answering phones and emails for the practice? Well, they were distributed, they weren’t coming to a central office anymore. Many clinics started to solve those problems, like, oh, what do I do if Becky’s at home and I’ve got another person that’s in another office. Okay, well we need software that’s going to unify those so that we can maintain a central view of the communication for our clinic. We started to see clinics use the downtime to look at projects like adopting CRM, customer relationship management software that would segment customers, give us better access to lifetime purchase patterns and deliver more automated recommendations or automated communications to nurture where our staff we’re too busy to do that. And I’m going to predict that one of the things that’s going to happen is if we see any kind of slow down at all next year is there’s going to be a huge number of clinics that look back into the recent [00:20:00] history and go those things I started to deploy in the midst of COVID, but maybe didn’t completely follow through with it’s time to pick those projects back up. So I think that’s one big thing guys is marking automation.

Michael: We can relate as we laugh now, but we had never heard the term CRM until we were at ASPS in Chicago just a couple of years ago and someone asked us what we use for CRM and we just stared at each other. And that made such a difference. I can’t imagine doing business as a law firm differently. It makes total sense.

Ryan: Yeah, absolutely. As I look into 2022, I guess, a warning for your office or for your listeners as well, which is that I think there’s a lot of technology advances that are coming back that will work against practices. And so they’re going to have to dial up their awareness, the research, the [00:21:00] trusted team that they have working for them to make sure they don’t accidentally get screwed. A couple of great examples just this week, right? The announcements about Apple’s iOS 15. If you’re not paying attention, what’s about to happen is you won’t effectively be able to track your open rates on your email marketing for like a third of the people who are on your subscriber list today. And it’s going to rob you of this third party data about what consumers, what your subscribers are interested in, and it’s going to make it harder to make smart choices about how you communicate. Google, we can go back just a couple months now. They changed the configurations for how they match. If you’re participating in Google ads you’re paying per click. They changed how they match what people are searching for and what you’re bidding for in a way that [00:22:00] broadened the matching and increased your spending. And in many cases, it automatically decreased the efficiency of those campaigns. And if you weren’t watching, if you weren’t tuned in, clinics would be suffering right now. And so being sure that you’ve got the right team and the right listening mechanisms in place is going to be super important in 2022 because a lot of these technology companies are making what they’re going to call improvements. So they’re systems that favor the consumer and don’t favor business.

Brad: First off, thank you for sharing. Because I have been reading about it, but you summarize a lot of thoughts I was trying to figure out what was the issue. So it’s very interesting to hear your perspective on it.

Ryan: Yeah. I’ve got three other little tips maybe for next year if you guys got a little bit more time. So the first thing I want to say in the last little segment here is that content, we talk a lot about content marketing. There’s a question like is blogging still valid? Is it still [00:23:00] worthwhile? What do we do as it relates to the practice as publisher and I’ll go on record content is still king. It will still be king in 2022. But what clinics need to understand is it is a game about quality. There’s a tremendous amount of noise in the marketplace. And so it’s not just about production, it’s about producing really great stuff. What we’re seeing is that as it relates to text content, ironically, with the rise of mobile, pages are getting longer. So in depth coverage, if you’re going to invest somewhere first, look at your procedure pages. Do you have a 1000 to 1200 words minimum in which you’re going super into detail about any individual procedure you’re hoping to promote? And the same would be true of your blog posts, right? The fluffy 300 word blog posts that say nothing about nothing are out the door. The things that are ranking today tend to be longer, more in-depth exposes [00:24:00] on a specific aspect of a procedure. The exact opposite is true in terms of video, we see bite sized videos being the more consumable thing for the consumer. The rise of things like TikTok I think are a testament to our shrinking attention spans. And so getting more comfortable with low production value video that you can use across channels using the same video on social media and use that video to enhance a blog post or a procedure page. Take that and push that video out to your email subscribers, but be thinking about not necessarily the quantity or the pace of production, but how do I take this thing I’m producing and have it be the most compelling version of that thing that’s out there in your market. The same content is king. If he’s second in line, I think 2022 is going to be a year when technical [00:25:00] optimization is actually kind of queen to the right that there was this big update. And if you guys heard about it just came out at the end of August, from Google, it’s called their page experience update, which is a little bit of a euphemism for your mobile website better be super-fast. So it’s now officially a factor it’s considered in how sites rank. It’s a small consideration, but Google’s been really clear. It’s going to increase in importance over time. So for clinics that are looking well, what do I do? Especially those that are already in a great position and they’re fighting for primacy for those top spots, those top rankings in their local market. It’s going to be the year where we have to pull back and ask, are we doing all of the new technical things, right? There’s something called schema, which is like an official way to bake information about your business, about your services underneath the code of your website that Google can understand. This is the year [00:26:00] to be making sure that you’re exploiting the opportunities present schema. It’s the year to make sure that you’re delivering a site where the mobile experience is just spot on. And all of those things are going to be important investments for clinics in 2022. The last big thing guys I would recommend, I think that this is probably going to be the year, and I don’t know how much you guys get this at cocktail parties. I get this all the time. Like kind of like glance over their shoulder and ask me, what’s the secret for success on social media? Right? Like if I just posted the right video or one good photo, or I tagged this other person who’s kind of an influencer of like that’s all it’s going to take to be successful on social. And what we’re really saying is practices are finally waking up to the truth that success on social media, it is a full-time communications channel. You guys can maybe take a second to talk about what it takes to assemble your podcast, right, and [00:27:00] that we’re seeing practices today that are hiring full-time dedicated, the titles vary slightly, social media managers, social media specialists, social media producers who are largely coming out of journalism or film school, or they’ve got specialized degrees in social media, who are filming and editing 24/7 and constantly posting original organic content on Facebook, Instagram, and more and more we see clinics moving to platforms like TikTok to shape from inside the clinic, not from the outside where agencies just don’t have easy access to the real faces of the practice on photo or video, the shape from the inside a real strategy to  dominate social media. So I think we’re going to see more and more of these new roles emerging and new business challenges for practice leaders to manage for those that are serious about finding success on social.

Michael: Amazing. I could sit here and listen for hours. [00:28:00] Thank you so much for joining us today. Ryan, we’re going to say goodbye now. We’ll break for commercial and on the other side, Brad and I will jump back in and follow up with a few observations from a legal perspective, but really appreciate you.

Ryan: Gentleman, thanks again for having me. It’s great to be here.

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Brad: Well, welcome back to Legal 123s with ByrdAdatto. I’m your host Brad Adatto. My cohost Michael [00:29:00] Byrd is still here, now Michael wasn’t that awesome catching up with Ryan. I mean, you said it near the end, but I could have listened to him all day.

Michael: Oh, yeah. He always has pearls of wisdom that he drops. I don’t know how much we can actually offer to add on to that expertise other than the one thing which is, did you know that advertising in the medical arena is actually regulated?

Brad: We mean there’s legal stuff that we should be discussing here?

Michael: Yeah. Brad, most medical boards regulate medical advertising.

Brad: Ah, well that leads us really nicely into first promoting the podcast. We’ve already done an episode this season with our partner, Dr. Jeff Segal, where we did the snake oil of patient reviews and we did cover, audience a lot of these same laws so I won’t go heavily into the details. But as Michael was saying, look, you need to be aware of the fact that because there are rules. Besides the medical board, the nursing board has rules, [00:30:00] but you also have on the federal government side, you have the FTC that will often overlook what you’re doing or the FDA. And basically the highest level I can give you is what they want to make sure is when you’re advertising that you’re not being false, deceptive or misleading, and there’s a lot of factors that fall into it. I think the easiest example I can give you is when you are going out and you’ve tried to promote yourself, a lot of times people want to use these really fancy marketing terms and they throw these things out there and talk about how wonderful they are and how they’re the best, that they do something and no one does it better than them. And if you’re promoting yourself in that sense, it sounds great from a marketing perspective, but understand if you’re referencing yourself that you’re the best surgeons and all of the country and no one does this particular procedure better than you. You better have gotten an award on that or been recognized by some well-known academy. You can’t Michael, unlike your case, where you give yourself awards all the time, you [00:31:00] can’t go out and give yourself your own awards. So you have to be very careful about how you promote yourself. And one thing I love about Ryan, he’s been in this industry since 2002. And so when you are finding someone to partner with, to help market yourself on the digital platform, this is a details matter moment. Make sure they are someone who understands your industry, your specialty, but more importantly, especially in the medical world because we have seen it too many times where someone didn’t. I’d love your final thoughts in the zoom in.

Michael: Yeah. I mean, I think more than anything, just understanding that as you are engaging in some of these strategies that Ryan or your marketing person kind of outlines for 2022 to recognize that you have to integrate compliance into that. And there are many marketing consultants who don’t understand the law. And so you can very unwittingly be led astray, [00:32:00] with what in many other industries would just be a normal marketing strategy and have a compliance issue. So you want to kind of vet whatever your strategy is against a compliance assessment.

Brad: Yeah, I think maybe tying it back to where we started, where he was telling a story while he was standing next to that volcano, the heat coming out of that vent. You don’t want to be standing there thinking your practice is doing great and you have all this great marketing material. And then the medical board explodes on you by renting hot lava across your practice and putting you out of business.

Michael: Are you calling a medical board a volcano?

Brad: No, but I’ve seen them get mad before and it does not end well, they will burn you down. Okay Michael, that’s all the time we have today. Next Wednesday we’re going to have a really cool guest joining us, we’re going to talk about how he went from playing in the NFL to becoming an expert on labs. That’s going to be Keith Gray. He’ll be joining us. So I’m excited for next week. [00:33:00]

Outro: Thanks again for joining us today. And remember, if you liked this episode, please subscribe. Make sure to give us a five- star rating and share with your friends. You can also sign up for the ByrdAdatto newsletter by going to our website at ByrdAdatto is providing this podcast as a public service. This podcast is for educational purposes only. This podcast does not constitute legal advice, nor does it establish an attorney- client relationship. Reference to any specific product or entity does not constitute an endorsement or recommendation by ByrdAdatto. The views expressed by guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent. Please consult with an attorney on your legal issues.

ByrdAdatto Founding Partner Bradford E. Adatto

Bradford E. Adatto

ByrdAdatto founding partner Michael Byrd

Michael S. Byrd