75. A Better Way to Practice Medicine via Direct Primary Care | Aleea Gupta, MD

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. 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So direct primary care is a completely grassroots independent way of setting up a primary care practice. There is a direct specialty care, or a direct care kind of branch, but the most common type of practice is just a primary care practice, internal med, pedes, or family practice, and basically it's set up along the lines of a concierge practice, but it definitely has a goal of providing affordable medical care to the community. And so by that, the physicians typically just set it up by themselves. You pretty much open up your business, and rather than billing insurance, you charge a cash membership that is based purely on age, so not on pre-existing conditions, and so that can range typically from around 60, 70 a month up to 120 again based on the age of the person. And for that monthly fee, they have unlimited visits with their primary care doctor, with no copay and no secondary bill for the visit. So it's essentially like a gym, so they're joining your practice, and they can see you as many times as they want per month, for that flat fee. And then the other side that makes it very affordable is typically the physician running the practice is able to offer discounted labs at cost, which are very inexpensive. And then typically meds at cost, and then radiology for cash prices. So for anybody who doesn't have great insurance or has no insurance, it kind of covers all the aspects of primary care in an incredibly affordable way. So that's the patient benefit, but then for the physician, it also means that you can have a small practice. Most people will cap it, say, 4 to 600 patients for a full time. You can spend as long as you want with your patients, you can see as few as you want per day, do a lot of virtual care. And then many, you can set it up around your lifestyle. So it's a really simple and fun way to practice. And I found out about it when my last job, which was an urgent care. I was working there a couple shifts a month and it worked really well and my kids were little. But the company that I was working for ran out of money and literally stopped paying me. And I just can't even believe that like this happens to doctors. You know, you show up, you do your work and you, you know, you just, you just don't get paid. So when, when I had to leave that job, I, and I'm older, I'm 50, I had worked a couple of places before that. I did not want to go back to the type of practice that I had in my prior jobs. Very busy, you know, 20 plus patients per day, very little time with patients. And so I started looking around and I heard about the model and I met one of the women who would open her practice. I think about two years before me and heard all about it, heard, you know, what are the basic things you have to do. How do you, how do you set everything up in a legitimate and legal way? And then I sat down with my husband and said, let's just try it. And if it doesn't work, then, you know, I will go work for one of the big health systems and just figure it out. But I'm four years in and I am full. My practice is capped and not taking any new patients. I hit the income goal that I wanted to and I really love it. And that's that's the best part. I think is that it's such a fun way to work that it doesn't feel like work. And that's why I want other young docs and just other docs to know that this is an option. You can make it work and probably enjoy it a lot more than you would in certain other settings. So I know why the price escalates with age. But for those who might be asking that question, why is that the case? It's because I think in primary care, you figure out that the older a patient is the more extensive, first of all, the more extensive medical history they have. And then the more likely there is to be for them to have coexisting conditions or their risk of different things goes up. So seniors tend to require a bit more work than younger people. But having said that, you can certainly have the opposite. I've got some seniors I never see and I have some higher utilizers who were younger. So and you again, there is no law telling you what your price point should be. So you can decide maybe you want to only switch prices at age 60 or 50. And some people do that. They have one flat price below, one flat price above. Some have one flat price from, you know, age 20. So you can decide based on your practice how you want. So you said your patient size, you know, is anywhere from 400 to 600, what is it usually, right? If you're working for like a private practice, that's, you know, not DVC model. So when I worked in an HMO practice in California, I want to say that our panels were two to three thousand. So I think on average, two to three thousand is about most primary care. I've heard that some places, you know, will inch up towards 4,000, but two to three is probably the national average. And that's an interesting space service. So how much time are you spending with the patient then, you know, now that you're five times less than what it would be. And again, it's, it's however much I want to spend. So typically if it's a new patient or a physical, I'll just block an hour. And if it's a follow up, I'll block half an hour. And that way, you know, sometimes there's never any need to rush. Many times we've done early or if we're not and there's an actual stuff, you know, that's plenty of time. The hour is plenty of time to get everything done. And likewise for a follow up, 30 minutes is plenty. Unless it's somebody who I know just needs a little extra than I might make it 45 minutes. Got it. Okay, I want to get more into your business model as well. But real quick, because I know a lot of people when they think about this model, they hear the word concierge. Or they at least see that and they think, whoa, that's really pricey. A lot of people stay away from that. Physicians and patients included. Can you explain the difference real quick between DPC versus concierge? Absolutely. So the concierge model I think has been around a lot longer. It is definitely insurance based. And so I may not have made it clear, but a typical DPC practice does not take insurance. So a patient can join and have insurance, but they can either way the DPC doctor will not be billing insurance. But with a concierge practice, there's a membership fee to join. It's typically by, you know, annual and the price point is at least double if not triple or more the price point of a DPC practice. Plus the concierge doctor will bill each time they see the patient. So if they have a visit or a house call or whatnot, they will bill insurance as well as, you know, in addition, they have the membership fee for the patient to belong to their practice. So for many patients, that is, it's just unaffordable because it's on the range of three to five grand to belong to the practice. Plus the insurance is getting billed. So that's one side. Whereas with the DPC practice, let's say it's on the higher end 100 a month, that's 1200 a year. Plus no bill when you come in and no copay and so no other fee to the DPC doctor, right? So there's that financial difference. And then I think because of that, most DPC docs inherently make it very clear what they're going to do and not do. Most of us don't go to the hospital. We don't make house calls and you're catering to a patient that is more middle class, blue collar, maybe even lower income could be executive. But you have to be clear that at this price point, you're not going to provide what a true concierge doctor can provide. And so I think once you kind of see where you fall within the two, it makes sense. You know, on your website, I think it's in your about me section, you said, and I quote, my greatest strength as a physician is my ability to connect with people. I love that. And I found it interesting that you led with that. Why is that important? I think that's important because when you when you truly can have a relationship with somebody that you anybody in life, honestly, but somebody that you are providing a service to. I think you just the experience is far better for both of you. And as physicians, you know, a lot of what we do is counsel people, a lot of what we do is help guide people towards a better state of health. And it's it's really easy to do and it's it's fun when you have a relationship and a connection with the person. It's easy to read, you know, how much can you encourage him this way or that way? What are what are they anxious about? What are their pain points? It just becomes very simple to see. And so I always thought that that was the basis of family practice and the basis of primary care and it's just always been the way I practice. But as I open this business, I found that it has a lot to do with how you run a business as well. And so people you meet along the way, how you help each other, relationships you build. It just makes the day to day a lot of fun versus when you're dealing with people that you don't see eye to eye with or are just difficult to work with. And then it just makes your day, it can be very draining to say the least. And I had that in other jobs, so I really appreciate not having it nowadays. But that way it makes me think about something I recently learned about. It's a concept of relationship centered medicine. You know, if we rewind the clock, 40 years, it's a medicine is just this very paternalistic point of view where you go to the doctor and it's like, okay, this is how things are going to go. And that's how they happen. And then there's this pendulum, which we talk about time and time again. That switches all the way to the opposite end. And it's all like now medicine is, you know, you have where somebody wants to meet. Look, we're just really good sales rep and it's customer service. And you're targeting to the consumers, right? And so today patients are so informed by the time they come to your clinic, right? Somebody comes to me asking for a procedure. They've already watched six YouTube videos on how to do it. And they're telling me like, well, I want you to do it this way. And it's always very interesting. And this concept of, you know, not necessarily physician centered, not person centered, which as good as this is a relationship center because it's a two way street, right? That's what it sounds like to me. Oh, absolutely. And I think the more you practice, the more you learn how to read people. And then it makes it a lot easier when you are trying to talk them into something or out of something or again, just meet them halfway. And I honestly don't give my, and I, it's something I tell my patients, you know, I'm not, I'm not here to give you a hard time. I'm honestly here to educate you. And if there's a choice you make that maybe isn't, you know, what my first choice is, whether it's vaccinate on, you know, not to vaccinate or to start a medication or not, I'm not going to get angry at you. I'm just, I'm here to meet you. I'm going to educate you though. And I will tell you what I'm worried about. So I'm afraid that if you don't do this, this could happen or now we have to be on the alert for this, this and this because, you know, you made this choice. But I don't think people want to be scolded and it's maybe they're still certain side places in medicine where that works, but I don't think it doesn't come right here. Yeah, you know, I think we live in a world, you know, a lot, a lot of with social media, a lot of, there's a lot of noise, right, and people don't get heard. And I think as a doctor or at least patients come to doctors, not only just to get healthy or to get treated, but it's also to always justify what they do on a day to day, right, whether they're smoking or whether they're not exercising enough. And again, I think you're, you, you nailed it. It's not about necessarily telling them that they need to do x, y, c, but encouraging them, coaching them, right. I think our role as a doctor has changed in a way, you know, to make it more about wellness, to make it more about coaching and educating, right, to actually take the root of doctor in Latin meaning to teach. So I really love that perspective, that concept, and I know it's definitely something that I've been using throughout residency, and it's, it's really funny because whenever we have a quote unquote tough patient, I'm that person that gets called on, right. And it's like, hey, we, we, we need you in the room. You, this, this patient's leaving AMA, what are you going to do? And I'm like, the problem is you're forcing something down their throat when they don't want that, right. But as long as you educate, you take a marker and you draw on the board, the anatomy, you start to actually get information like through their minds, right. And so I just, I find that model of at least at least patients that are cared to be very helpful for sure. I want to transition more into your practice. And when we do this, if you can, can you teach it in a way that's for let's say me or resident that wants to get into DPC, but also for a patient who may not have heard what DPC is, because I still think it's very unknown. So let's start with insurance. So you, you talked about how the patient would bill for insurance, right. Let's get started, I guess, in terms of teaching a resident, how they would get started with this practice, especially from the bad standpoint. Sure. Okay. So the first thing is obviously to do your homework, because you're opening a business. And I had no business background. Most of us don't. Of course, there are a few docs who are, you know, MD MBA or, you know, more entrepreneurial to begin with, but if whether or not you definitely want to do your homework and find a resource, whether it's how to open your DPC practice, whether it's working with a mentor, but get your ducks in a road to open the practice, right. And so things you want to do, you have to start a business entity, things like a business license, open a business bank account, you have to find a physical space where you want your practice to be that has to be zoned from medical. So you can't just go into any old, you know, space, you have to make sure it's zoned from medical. And then once you pick your space, right, then you have to start setting it up to provide the services you want to provide, whether that's buying your equipment, whether if you want to do procedures, everything you need. You do not have to start with staff and that's something I think most people are surprised to hear. I started without any staff and I still have barely I have maybe like five or six hours of admin time a week, but that's in I do everything myself. And many of us start that way. And then as you grow, you can decide you want to bring a staff member on or if you open and maybe you have you worked somewhere else and you're bringing patients over and you bring a staff member with you, but many of us are in the case of coming out of residency, you may not have any patient base. So you're just going to open your doors, right. And then you want to set up, so you have your, you know, your business, your LLC setup, you have your bank account, you have your physical space, then you need to start with a DPC centric EMR. So I use one called Atlas. There's a couple of them. But that to me is actually one of the most fun parts of running the practice because everything I need to do the EMR does for me. So I keep a credit card and file for the patients, it builds their monthly membership when we order labs and meds, those go through the EMR as well. I do my charting, I can text people, email them and that all gets saved in their chart within the EMR. So if they text me and we're talking, okay, you know, let's start, you know, antibiotics for cellulitis, go pick it up at the pharmacy, all of that is in their chart already. And if they've emailed me with questions, those emails are all funneling. So I don't have to go back and double chart. So I really love that because and it works really well in my phone. So I can be in line waiting to pick up my kids and I can take care of patient things before they come in the car or, you know, in between washing dishes, I'm handling stuff because I can just do it really quickly on my phone. And so then you've set everything up, you've got your EMR going, you can start enrolling patients, you can schedule their visits through the EMR and then, you know, they start coming in. The hardest part is probably marketing your practice, especially if you don't, you know, have an existing job where patients are going to follow you. And so that's a whole nother side topic in terms of how you build your practice, but opening this type of practice is a lot simpler than a typical fee for service private practice because you don't need a billar, right? You don't need all these contracts with Blue Cross and United, you don't need, you know, half of those things because it's just you and your patient and that's about it. You still, I think, and everybody should set their practice up to the standard of practice. So, for example, any tests I do are clear-waved. I log all my labs. You know, you have OSHA and the fire code and all the other things you need to have a business because you want to protect your license, right, at the end of the day. But so much of the administrative things that you have to do in the fee for service practice, they just aren't even there because you're not taking insurance. And that's probably what simplifies it the most. How, like, what does it mean when a site is zoned for medical? You mentioned that. That's pretty easy. It just means that whatever building you're working in has gotten that approval that this is a site that, you know, you can have a medical practice on site. And that's not like that's just something that the owner of the space has to figure out and then let you know. And I think it's sort of makes sense anyway because you usually want to have a sink. And so in order to have a sink, most places will qualify. So it was very easy for me to tie the truth. I don't know if anybody would really say anything if you try to open in a space, but then it becomes the liability of the owner, right. So in that case, if you're opening a medical practice and he's not zoned for it, he's probably not going to want to have you because it's his building. So that's just an detail though. And, you know, in most places, there are tons and tons of medical spaces. So that's not the case. Gotcha. And it certainly doesn't it's such a low hang for it doesn't seem like a place where somebody would want to cut corners, not that you'd want to cut corners anywhere. But you also mentioned you want to use, or if I heard you correctly, in EMR specific for a DPC model, why can't you use something like one of the popular ones like Epic or, you know, God, Athena is so terrible, but yeah, a certain or something else. You could, but I think it would be very cumbersome because it had and it would probably cost a lot more. I have no idea what they cost, but I know that the one I use costs 300 a month. And so that to me is very affordable because and then it runs the credit cards that the patients keep on file and then sends all those payments over to my business bank account. I don't know if Epic, which is what my husband uses. And as you said, as well, no, I don't know if it's set up to do all those things. And if then, and also if it's going to cost a lot more. But there are three other ones and there's more of a market for different EMRs that will also, you know, bring your faxes in the faxes in the patient chart and keep everything all together. This is an oddly specific question, but when you were in the market and setting up that EMR, considering how important it is to set that up, you know, to build your systems upfront, you've talked about that before. Were you able to trial different EMRs for like two weeks at a time and say, Hey, this is the best for my workflow. Can you do that? I think you can. Nowadays, I think you can. At the time I opened Atlas was the main one and there really weren't a lot of other ones. And so much of what we do in DPC is you don't want to reinvent the wheel if you don't have to. And so I talked to other DPC docs. There's a DPC docs specific Facebook group that is only for physicians and specifically physicians interested in DPC. Maybe you have to be brought in by another member, but there's, you know, many, many threads about, well, debating one EMR versus another kitchen with one EMR. What happened when, you know, you didn't like it and you changed your mind. So at the time I opened, it was really only one that I liked it. Other people liked the newer ones. I am very old school and so I kind of blew my mind that you could just use a macro and have an entire, you know, HPI and PMH filled out for you. Because I'm from that, you know, stays when we hand wrote all that stuff in the yard night. And I can still remember how much my arm would A for writing 10 HPI's by the time the morning gets out of the box. I mean, like it's been out with one hashtag. So I went with one that kind of looks like that. But there are other people like this. It's whatever your preference, but I love the one I have. I don't think you're going to have a problem. I'm still waiting for the EMRs that, well, they should be coming out hopefully soon. But you just talk and then the AI just kind of puts down whatever you need or wherever you need it. And you no longer need scribes or whatever. But, you know, speaking of startups, I do know there are a bunch of companies now, even probably in the past four years that you started who are coming out with these kind of like DPC models for EMRs. With Atlas, are there specific lab companies that you work with or are you just drawing labs as if you would, you know, if you were epics or any other kind of EMR? So when labs, the first thing you have to do is you have to find a lab that can do your blood work on your patients. And so since I didn't have staff, I wanted to use a lab that had a local draw station where I could send patients because I do everything. But drawing blood is one that it's far too time consuming because it's not just collecting the blood. It's the spinning and labeling and all of that. So I knew that that was one area that I was just not going to take on. And so there we have the big ones around here lab corn quest. And so I chose the one that was closest to me because then I could send patients and they bill, you know, $3 for a lab draw. So it's a very small fee and then the patients can go in fasting and you don't have to be here to bring them in. So what I did is, and what most DBC docs do is they approach their local rep and they ask to set up a wholesale account, which will usually give them a very big discount on the prices of the test. So typically my prices are 75% off of what lab core bills insurance, right? So let's take, you know, CBC is an example. My price for the CBC is like $4 and so and it will say 75% off the regular price, which means that lab core bills insurance, $20, right? But then insurance is probably not going to build $20 to the patient or whatnot. They're going to bill more, right? And so that's where all this marking up happens. And that's why the price of labs when you have insurance, many times it's not $5. It's going to be a hundred for the CBC, right? And then you wait to see, have you hit your deductible in which case the insurance will take care of it? Have you not in which case you will probably be paying the hundred dollars. So I set my, my practice up with lab core. And then once you have that account, when patients go to the lab, you order the labs through Atlas. And then the patients go to the lab, do their blood. They don't pay anything. And the end of the month lab core sends me a bill with all of my patients who they took care of and I paid the bill. And that's how we keep the prices down. So I'm trying to explain it simply. But in essence, it's patients being members have access to this discount. And then lab core and I, we handle each other. And then I collect payment from patients. So essentially part of being a CBC practice is you don't mark that you don't mark that price up very much. So I add on enough for credit card fees and taxes, but essentially it's like being percent above the base discount price. The patient is getting still getting. And you're not losing money because you have to pay the taxes and make credit card fees on everything that passes. So essentially the fee that they're paying monthly is already covering the labs and whatnot. So. So some DPCs do that. So they bundle that into their monthly fee or their annual fee. Some of us don't. And so I don't because I feel that the price point of being a member is really, really good for what the members get. They get multiple visits for month if they need them for no extra charge. So I do the labs as additional. But some people include them. And I think it works well for my business model because some patients, you know, they only need one set of annual labs a year, which might be 50, but other people, you know, they need labs a couple times a year. And at this price point, it is a very manageable expense for the bulk of patients. And they are so happy that many times if they have insurance, most of the time they say, I just want to do them through your practice. I don't want to wait and see is Medicare going to cover or not cover. There's always this big deal about vitamin D. I don't know why vitamin D ends up being built out at like $250. And I'm like, why it's like $17 for cash. So let's not even deal with it. Let's just do your vitamin D and run it through the practice. So. It's a nice way for patients to save money. Yeah, and I think for so just because what I love about kind of what you've explained there is, and you've talked about this before in previous podcasts is just you're very transparent, right, but they're about the whole conversation. It's clear. It reminds me of I was listening to Adam Grant and he had Mark Cuban on recently who I think I forget what his company is for like pharmacy and they're talking about his big thing was the reason we're selling is because, you know, he's talking and talking about the markups. But they're doing markup to it's 15% for them, but they're so transparent about it and comparatively speaking with the traditional healthcare model. It's just it's a ridiculous amounts of savings and people see that they understand that and most people can appreciate that. You know, hey, this markup is okay because again, you are providing a service and lots of times people are providing products and that's okay that they do have to pay some somewhat as long as it's not unreasonable. And I think the best thing about transparency with respect to all this is I've had countless conversations and I've actually been on the side right on the patient side. I think we, Darce was talking about the AI, I think Peter Valenzuela, one of our previous guests came and talked a lot about that and I mentioned this story where I was just fighting a bill which just made no sense for the longest time. And every time I would call the insurance company, they would reroute me to the doctor's office and they just couldn't finger it out like where the mistake was like they could not figure out their own billing system of like how it translated into my benefits and why I was being charged again because I just knew my benefits inside and out. And so, you know, that type of computing system when nobody gets and people are just likely to believe, hey, like something has to be wrong here. It doesn't make sense that I'm vitamin D, which is a quick stick cost like, I don't know, a couple hundred dollars. And I think for the record, it's important to note like I'm looking at your pricing here and I mean, you've got like for somebody ages 18 to 30 for an individual membership, that's $75 a month. Is that right? Yeah. And you know, I know, Darsha, I see that question. And my immediate thought when I look at that is wow, that's amazing. And in it, you're talking about how like unlimited visits, right? And I know you mentioned elsewhere that you kind of make yourself available 7 am to 7 pm. I can't help but think is if somebody has unlimited access in that amount of time that you've you've allotted for work hours. How could that possibly be a good business model, a profitable business model, right? So so much depends on how use who joins your practice and how your practice evolves, where you're located in the country as well. Kind of, you know, you have a little bit of play with your price point there. People are charging a little bit more in downtown Chicago, New York City versus in say rural Ohio or you know rural Texas, but so much depends on who's in the practice. So mine is sort of split between uninsured small business owners and employees and executive or more chronically ill patients, a couple of Medicare patients who need a bit more personal care than they can receive even using their insurance. And I didn't really set out I've actually never really discharged a patient for my practice believe it or not in four years. You have that option if you think that someone is you're not able to provide the level of care that you want to within this model. But having said that, I really think that if you do the work upfront to take care of your patients, things settle down because the majority of them they actually don't want to be having appointments coming to the doctor. Most of them just want to get things taken care of and monitored over the course of the year. So hypertension diabetes, you know, spaced out every four months or six months. So some things settle down in time, but to answer your question, filling your practice with a balance of higher utilizers and lower utilizers is important for the model to be sustainable. So the discharge part, I get that. I mean, certainly nobody wants to do that because you never want to feel like you're abandoning a patient just because they're utilizing the resources. And again, I want to be clear that we're not suggesting that somebody is inappropriately using the resources, but just more than they want to. You know, the another solution I would see is, would you ever consider just saying, hey, we're going to upgrade you to the next level of membership, even though you fall in this age bracket. I know you have it set out there. Did you consider something like that? Would that make sense? I had that conversation with one patient. And he was willing to go up. And then I said, okay, let's just see what happens. And we worked a bit. We worked through things and we got things to settle down. So four years in, I feel that pretty much everybody I have is using things appropriately. And because they're with me for different reasons, the ones who are more uninsured small business in the small business world, they really are receiving a financial benefit. They're usually a little bit younger, slightly healthier. So they are coming in as much. And the ones who are coming to me more for access, who have insurance and who could go somewhere else. Even then, over time, things settle down. So I think it naturally resolves itself. At least that's been my experience. I'm curious to know how you communicate with your patients in regards to them maybe expecting more about your scope of practice, right? I'm thinking a lot of people who may choose DPC or let's say concert medicine or this model away from kind of what we know as healthcare. I think they are my doctor, no functional medicine, integrative medicine. They should be able to do X, Y, C procedures. What's that initial conversation that you have with your patients, especially the ones that may not have followed you from your previous practice? That's a great question. I am a straight up old school down and dirty family doctor. That's who I am. That's what I've been doing for the past several decades. So I just tell them straight up that this is what I do. I'm not a functional medicine doctor. I'm not a naturopath. I'm not anything else. And I completely believe there's a place for multiple types of approaches to medicine and there's benefit, but this is not what I do. And I think once they hear that, they get it. I can't be something that I'm not. And I think that's kind of, it sort of stands to reason for most of us, right? That you have to be authentic. You have to be who you are. And if this is not something you provide, you just don't. And there are others, by the way, I mean, there are other DPC docs who do more wellness and functional medicine and they don't do as much general primary care. They're all sorts of ways now that people are structuring this model or even just other types of practices. Some people will do only wellness and then they will encourage the person to have a separate PCP for six visits and chronic illnesses or, you know, things like lower back pain or things that maybe they are not going to be addressing. So kind of some patients want that and their patients that come to me that sometimes still go for a consult with a functional med doc or with an acupuncturist or with a. And as long as I feel as long as we are open about it and we keep everything upfront, then I'm fine with that because I Western medicine has its limits, as you know, and there are things within chronic care that sometimes you can't, you just can't, you know, fix them. So if there's an alternative way and it works and we can all keep company, then I think we have to be a little flexible nowadays because, as you said, the consumer and the patient are informed and they're looking for more than just this patriarchal type of health care. And I think it's important to just have those collaborations because if the patient benefits in the long run, then that's our goal. What about procedures? What kind of procedures do you do? You said you mentioned general primary care and I know that a lot of them, the medicine doctors will do some preventative screening, biopsies, that kind of stuff. Is that part of your practice as well? Yeah, so I do a women's health. So perhaps we use STIs. That sort of stuff is very, you know, bread and butter for me. I do a little bit of Durham in terms of skin biopsies, simple ones, you know, shades or punches, but I am not a particularly procedural person. So that's not my real house. It's not an area that I really like to do a lot of even when I worked in fee for service jobs, but there are other DPC docs that are doing tons of things, joint injections. There's one person who is doing, I can't even believe it, DPC and OB in Texas and she's delivering babies. As a DPC doctor, you know, under the auspices of the OB team, I mean, just amazing. And so a lot of people are doing far more than I do, which is to their comfort level. And then there's room in DPC of course for aesthetics if you want to bring that in. Again, I don't really have time to learn it and bring it on, but a lot of people are and they're starting out with, you know, fillers and Botox and lasers. It's also a nice side stream of income, but it's also because that's obviously additional and it's cash. But it's also just, I think, a different way to break up your day to day. You don't want to necessarily only be doing chronic care preventive. It's just a different type of medicine that they enjoy. So there's scope for that. What percentage of your practice is in person versus virtual at this point? So I'm going to say maybe 50-50 feels like 50-50. Obviously in the pandemic, everything switched to virtual immediately. And there was no additional charge or anything different for patients. I just kept going and just kept seeing patients virtually. And I split my week up Monday, Tuesday, Thursday, I see patients in the office or virtually just depending what they want and, you know, what's better for them. And then Wednesday, Friday, I do probably like a half day or less than a half day of admin or referrals or follow-up stuff. I try not to do any care on those days, any patient care unless there's, you know, that's the only time I could set up a phone call. I try to put all my clinical care on Monday, Tuesday, Thursday. And so far, it works. So with your virtual practice, did you expand geographically? I know you mentioned different DPC models in Center City and that kind of stuff. But are you only practicing in the state of Illinois or have you expanded out? So I only practice in the state of Illinois because I'm only licensed here. But I have one side caveat which is that Florida allows you, Florida is the only state that allows you to have a telehealth license. Okay, there's a loophole for basically any of my patients that go to Florida. I can still provide virtual care to those patients, but not to new patients because I'm not officially licensed as a Florida telehealth provider. But I have Florida's permission to see my patients Monday. Which is you can imagine we have a fair amount of traffic between Florida and Illinois because of the winter, right? Do all snowbirds only go to Florida? How can nobody go to Arizona or Southern California? Is it because it's too expensive? I would totally go to SoCal, I don't understand. I agree. I grew up in Florida. Arizona is getting popular though. Tucson and Scottsdale are definitely picking up some newcomers. But did that answer a question? Yeah, so yeah, only in the state of Illinois. But not all of my patients are nearby. Some of them are in the city. Some of them are in York, which is like almost places like about an hour away. And I just tell them up front. You know, I try to see everybody in person every year, once a year. But beyond that, it just depends on how acute they are. And they also know that if something's happening, I'm here for advice and triaging. But obviously, if you have an immediate issue and you can't drive an hour to see me, I'm going to guide you to purging care or the ER or whatever is nearby to get that addressed. But people just really appreciate being able to get questions answered quickly. And no, hey, what am I supposed to do for this feasting? Is it infected or not? You know, and I'm on the road and I'm not a GI bug. What do I do? I mean, it's so fun. So just simple thing. You just get an answer. I love it. Yeah, can I ask. So you talk about people emailing you questions. How much of your day is split up, maybe from number of patients you see, versus number of questions you're answering throughout the day for your patients? So I like to do texting because I've been solo the whole time. So for me, texting works a lot faster than phone. So I get literally, I don't even know, I don't know how many texts I get in a day. But I can handle things very fast whether it's, can I move my appointment to two weeks from now or can I get a refill or I'm not feeling good or I have ear pain? What do I do? So I, and I'm very strict about my time parameters of well, when I'm available. So as you guys heard, 7 a.m. to 7 p.m. Monday through Friday. So I get the bulk of everything during that time frame. And I get it answered in that time frame. After 7 if it's not urgent, it's not going to be looked at till tomorrow, same as the weekend. And there are a couple people, you know, they forget and whatnot. And I just generally remind them if it's not urgent, it will be handled Monday through Friday. And I think keeping that parameter really makes the evenings and the weekends not stressful at all. And if someone, and the other thing I do is, if I have somebody who's sick, I check on them usually daily until whatever it is. So this is a great help with the opening of that's cooler. You know, they're nervous and they don't know when to return in the corner, when do I worry. And simple things, they don't know, like, take rope attest in DM for the cost. You don't have to do so much with cost or, you know, talking about packs a little bit in the first few days. You want to start or do not. Just sending them a text every morning for like a couple days until I feel like they're out of the woods. I think it really helps because then they know that this is not for God. And that's a huge comfort that doesn't really happen. Service, you don't have time, who has time to text, you know, 25 patients every morning. You may have that many that are sort of on watch, right? You just, you can't with that kind of volume. So urgency is subjective. And I imagine as, you know, I think those established patients, they probably understood. And you after being explained, hey, this is an urgent matter. This is an emergent matter, right? This is what you can call me before. But, you know, again, my wife is a pediatrician and everything is urgent. Especially for new parents, right? So how do you establish those boundaries and how do you educate them like on that? Is that frustrating, like especially as you're onboarding and getting more patients? I mean, getting from zero to 600, that's a, that's a long way. And I can't imagine you built that over two months and probably took a couple of years, right? You said you're four years in. Yeah. So remember mine is super small because I'm part time. I have part time malpractice. I have part time hours. And that's why you heard me say, I am only in the office three days a week because I am part time. And so I intentionally set things up that I was going to have the volume to make a part time schedule and I'm going to live a part time life. And I'm laying that out like that because I also think it's easy to fall into a money trap with this model too. So obviously 600 patients is going to bring in a lot more money than 200. But you're going to have to look after those 600 patients and you don't know, are they all young and healthy? Or you don't know how it's going to fill in how you're going to control how it's filling, right? So you have to be mindful of how you want this practice to fit into your life. And that's where boundaries are so important. Does that kind of answer a little bit? It does. Yeah, it does. So let's talk a little bit about outsourcing, right? You mentioned at the outset that it's very important to, you know, establish your systems, emphasize on the EMR, how you can kind of coordinate everything through that one system. And initially, you said it's not necessary to kind of have staff. But at some point, right, it's that tipping point where you're like, you know, I think it might just be worth it to have a little bit of admin support, even though you're part time, to kind of feel some of these messages kind of filter through and reach out to me. Have you found yourself that you're at that point? And how does one know that they're at that point? That is an awesome question. I think you really have to look at your numbers, know your numbers in terms of how much do you want to bring home? How much are you willing to pay for a staff? How much time do you have to commit to? Because in person, it may be hard to find somebody for, say, less than 10 hours a week in person, but you could get a virtual assistant and, you know, have, you know, go by the hour with them. So you have different options. For me, I just was determined to keep it, keep my overhead as low as possible. But I knew that came at the cost of me working. So when I found that the number of repetitive tasks that were sucking my time in a way that I was just kind of dreading getting to them, was building up, that's when I started looking for some help. So for, and it's different for everybody, but for me, I, what it was for me, it's going to sound really silly, but it was the filing of documents, the taking things out of the fat, moving them into the charts and labeling them and all that, like when they come in, that's the part that was driving me crazy, or all of these things coming back from when you prescribe something electronic, and you've got to download that and put it in the chart. Like that kind of clerical stuff was where my outer limit was. But the other things I just, and because I started with essentially zero patients, I set everything up as I grew. So by the time I got busy, I had already figured out how to do things very fast. And I was okay, we've already done that. We've already done that. We've already ordered streptest. We don't have to order them again for two years. You know, like so many things were just done. I've already bought my furniture. I don't need to buy anything more. I already have paper gowns that are going to last another year. You know, you, you, all these things just happen. And there's less and less to do. And so the repetitive things, that was my, my indicator to myself. Dr. Group, I ever see joint practices or is DPC typically a one man sport solo solo practice? No, there are quite a lot of joint practices. There's a practice in gamesville that opened up with two women from the get go. There are quite a few big ones. I'm going to be part of Dr. Shane Purcell. There's a vanguard within DPC of, you know, the earlier docs who started, who many of whom were now on the board of the DPC Alliance, or they were the ones who set up DPC docs, Facebook group, some of them lobby, lobby the government. So there are a few that have set up practices anywhere from two to four people. There's a place in Florida and Pond of India that's hiring now. They filled, they want to bring somebody on. So I think I've seen both. I've seen people starting out as a group. I've seen people starting out individually and at that age. You know, but I think probably the difference is, I still think each person, you know, I can't even say that. I was not saying each person has their own individual DPC. But that may not even be the case, because in some cases they might be splitting the same patient. But, you know, they may have decided they want to do it that way. Or want to each have their own panel and then cover each other on call. Yeah, sorry. I was just going to say going back straight out of residency. Do you wish you directly went down the DPC model? Or do you think it's worth somebody going through the traditional healthcare, you know, practice, especially for family medicine? Let's say get that experience, get that patient base, and then transition over. So, in my opinion, that's an easier route, because number one, you get more experience in a fee for service practice upfront, because you're going to be seeing more volume. And I remember an attending telling me it takes about five years out of practice to get really comfortable with being by yourself. And I remember that feeling of being unsure and calling people or just, you know, having to see something several times to feel like, okay, I know exactly what to do. I know what to do when this goes this way or that way, right? So, you set up your own practice patterns. And then loans, whether or not you have loans or whether you're going to be, you know, taking out money upfront for this practice to build, because it takes time. You may not have a patient base to start. You may have, I mean, it took me a year to break even. And then it took me another, you know, I didn't start making money until my, after my first year. And I didn't hit my goal salary until my third year. So, that's a long time to be without that second income if that's part of your, your budget, right? Now, mind you, setting up a private practice of any type can have that same lag time, whether it's Durham or whether it's, you know, plastic surgery or E&T. It can still have quite a while until it builds. And you have to expect that trajectory to be there. So, I personally looking back would still have taken those five years of experience and, you know, to make a real dent in my loans before opening. But there are people nowadays opening out of residency. Paul Thomas in Detroit opened out of residency. Jake Norris in Nevada, I think it just graduated and opened. Some of the younger docs in you guys, age group, are doing that. Most of the older docs like me, you know, obviously had other jobs before we came to DBC. But I do, I do wish I could have started earlier. I, in some ways, I wish that, you know, a couple of years earlier would have been fun. But having said that, when you have small kids, as you know, they're, they have a certain demand. And so, you may not have the mental space to be able to start a practice and let it grow when your children are that little. So, this depends on you and your life circumstances. And much is the case with really any project. I mean, take this, this podcast, right? We've been, we're, we're coming up on two years in just about a month. And, and that's time investment, particularly because we both started when we were trainees, right? So, but I think there's a, when there's a purpose. And previous guest, Brian Suter talked about, you know, that's why you have to have pleasure in the process when you're doing these types of things. And so, I know we didn't talk a lot about your journey and kind of how we got there, you know, we touched on here and there. But I'm of the firm belief that everything that you do, there's an opportunity cost, right? It's good. And we have to justify as we make those decisions. And so, I'd like to know one thing, right? You, you've worked at quote unquote traditional modeling, you switched over DPC. One thing that you've gained from making this switch that's been invaluable. It can be really anything from your personal life, business, whatever it's fed your, you know, curiosity, whatever it might be. And then one thing that you've lost. So, the one thing, the main thing that I've gained through opening a DPC practice is true joy in my work. I never had that in any other job. I didn't. I wanted it. I had joy in my patient interactions, like just that little time with the patient. That was where the little bit of joy was. But it was just swashed by having to go so fast and having this schedule that people could just stick people in. And then you thought you're going to be okay with 10 for the day and now for the half day and 10 suddenly became 12 and 15 or whatever number it was. And I remember hating, hating people having the power to make me work more when I was already working so much. And so the difference with DPC is not only is the patient care far more involved. I mean, endlessly enjoyable because there isn't that rush and that high number and that need to perform to somebody else's standard. But the business side is really, really fun. And I really enjoy because it taught me to use a different side of my brain. It gave me a chance to be creative. It gave me a chance to be sort of fiscal in a way and learn. How can I do this for less? How can I, what can I do to keep these numbers down so that my income will grow? And so that kind of challenge is fun. And I literally hours can pass, hours can pass, and I'll be like, oh, wait, wait, four hours. Okay, I gotta go home, I gotta pick somebody up. So truly, truly enjoying all facets of my job is what I've gotten from DPC. And the one thing that I lost was having as much time for myself and specifically for self care as I did before. Because when I was just working two shifts in urgent care and looking after my kids, I had more time to make sure I worked out at this time. I made exactly this. I didn't comfort eat or whatever. And so when you open a business and again, when you're building and trying and striving, something has to go. So a lot of the self care I used to do, kind of split by the wayside. And I just used to be the bare minimum. Barely do some kind of workout a couple times a week and that was that. But now that the practice is full, I am able to bring some of that back. So I'm now opening up that part of my life. Yeah, I love that, right? I think our generation, mine and all, as well as Gen Z, you know, if you look at the data and what we kind of value, it's that autonomy, it's that flexibility. But it's also having that passion to not only just focus on one thing, right, which is just medicine, but being able to live a life that's more full. And it sounds like you're able to truly do that, right? So I can only see more and more people as they come through this ladder of medicine and training, start to understand DPC and really make a push for it to try to understand. We're also seeing a lot of doctors try to become more business oriented, as you said. Now, you have a real on social media, so obviously a lot of people can check out your Instagram to learn about DPC, you're putting reals almost every day, really talking about the different facets of it. What are other ways, you know, are there courses that people can go to learn the business side of things or just understand the different systems that need to be put in place? What do you recommend or where do you recommend young doctors or even older doctors start? So I really think everybody has to read Doug Harago's book because it's sort of he's one of the early founders of DPC. Of course, you know, he also has a it's not quite a podcast. It's called my DPC news. And so it's a daily email. It's kind of like a place where he pulls together different things that are happening within DPC, whether it's a podcast or whether it's a course or whether it's just a daily blog. I guess it's a blog, you would call it. So that's called DPC news. There's the my DPC story podcast that Maryal conception runs and that is amazing because it's our long episodes with individual DPC doctors telling their story. So how they got things going. But the book how to start your DPC practice by again, Doug Farago, everyone should read that it's quick. It's a paperback. It's been updated. It's an audible. It just kind of gives you the lay of the land very quickly. So you have an idea. This is kind of the quick and you know, overall, overall theme of what I'm going to be getting into. And then after that, I would recommend joining the DPC docs Facebook group because you can get a lot of one on one connection and information. And then the DPC Alliance is also amazing. And they have a curriculum. So, you know, episodes and posts of different topics within DPC. And there is a more extensive course that goes through many of the modules that or many of the legal steps and things that you may want to set up. And that's can really like core. She sells her course and you can go through it to pull out different things you may need to set up your practice. But everyone has a different budget. Everyone has a different, you know, time commitment. But if I had to pick one thing, I would pick read that book and look at the DPC Alliance website. Because I think there's a lot of good content on there as well. That's just easy to navigate. Cool. So you're on Instagram. Again, you're doing reels. I think you have a lot of great content. Where else can our listeners find you? I also just opened Tiktok. I'm still new to Tiktok, but I have the same account over there at the period of the helicopter. As you guys know, I know you guys are over there too. It's a different space, but it's also really fun to connect in a more natural way on that platform. So either way, same account. You know, on that note, actually, since we have a couple more minutes, I would like to get your perspective. You talked about this on my DPC story, social media tips, right? Because I think you do a great job. And I think it's since you brought up Tiktok. I was recently, I don't know where I saw this. I probably saw this on social media. Somebody was talking about kind of just the revenue that all the social media platforms has generated over a certain time over a decade. And Tiktok is like at four billion within I don't know. It's like basically the slope is three X or four X. What what Instagram was, which I think history historically was the best one. So what are some tips for individuals? Again, you know, the up and coming docs are really maybe even the folks who are not millennials who are not as comfortable getting in front of the camera, getting on Instagram, getting on Twitter, that kind of stuff. They pay you need to get on these platforms. How do they get started? So it's funny that you ask this. So we have there are two big DPC summits. I should have mentioned this two big DPC summits that are held just about every year. One of them is the DPC summit, which is kind of under the umbrella of the AAP that was this past July. And then there's a nuts and bolts that's set up separately. And then that one I think is later this month, but those are also two great conferences to attend if you're interested in DPC or your you know, a doc who's thinking about taking the leap and they have different tracks within one, one, two, one, three, one. So you can go to different lectures based on where you are. Are you about to open? Have you been open? Have you been open a while? So something else for the viewers and listeners to keep in mind, but this past summer, my talk at the DPC summit was about exactly that, which is social media for DPC docs. And I gave that talk about Instagram. And then I'm about to give it at another workshop, but this time it's Instagram and TikTok. But to answer your question, I think one thing that's really important is what is your purpose for being on social media? And for me in the first three years of my practice, it was to market my practice because, again, remember, I opened with no patience. And I did all these different things to market. I went door to door, I joined the chamber, all of that. And I figured out that you can use, you can use Instagram in particular to really find your ideal patient and engage with them. And kind of show them more about yourself and vice versa. And that relationship definitely brought patience in through my door. But it's what I would say in a nutshell, just to keep it short and simple is post content about DPC and about your practice. And don't worry about numbers and all these other things, but find your ideal patient, you know, for many DPC practices, it's small businesses. So find small businesses that are local like restaurants and barbershops and landscaping guys and follow their accounts engage with their accounts, support their businesses. And that's how they are going to be interested in you and join your practice. And that's kind of what my little niche niche niche niche, whatever you say within the whole DPC community is, which is trying to teach other DPC docs how to use that, you know, how to use the platforms to bring patience into your practice because none of us really need to be influencers or necessarily brand, you know, brand sponsored or anything, but you're trying to build your practice and social media is definitely a good tool for that if you use it the right way. You know, I see both sides of it, right. I'm going to play devil's advocate for a second here. I do really appreciate kind of just the overarching, you know, philosophy that you have that we shouldn't look at the numbers because that's not why we're there. That's not the purpose of it. Right. And you also mentioned that at this point, that's not your like your lead generation, right. But now you're you're primarily doing it just to spread the message or DPC, right. I mean, often people will talk about, hey, look, the system is broken. We need to fix the system or we need to do it better way. And again, the it's not lost on me. The name of the show is medicine redefined. So obviously we think that the things can be done a better way. But at the same time, if you are trying to make some type of change, make the system better in whatever way that we all are, isn't it important to have more numbers so that your voice, your message can touch more people and that can spread the love further out. So by focusing on that. When that also be accomplishing the goal or do you think overall that's not that's not where most of the benefits coming from. No, and I probably should have qualified when I said don't worry about the numbers. I just meant in terms of DPC docs who are trying to get onto the platforms to grow their practices, right. Because you're trying to get maybe 600 patients and you want to get to those people and get to know them. So to that in that sense, I just meant, you know, one of the things I tell them is not to get too caught up in the numbers because you can still find your patients. If you put your time into engaging with them, even if your, you know, your your account is not huge, but my account I actually intentionally switched it over about a year ago when I started to fill my practice because I wanted to do exactly what you guys are doing. Which is talk to young physicians and future physicians about what is happening in healthcare and how to kind of find the best way to practice nowadays that where you know where you can find joy and autonomy and all these things that we're looking for in our work, right. And I haven't actually gotten to it yet, but one of my goals and perhaps it would be nice to, you know, pick you guys brains about how to do this, but I think you need to hear more from other physicians who are practicing in different places. And you can't many times you can't hear about it until they leave and so for one of the big themes that's one of one of the big things that's happening in the landscape at least around here is most small practices have been bought up by larger medical groups. So big medical systems right have been absorbing these small practices over the last 10 years and then private equity is also coming in and buying out these medical groups and so what's happened to physicians around here is the quality of work life has declined dramatically and income compared to what activity has changed. And but you don't hear these stories when you're in training right who's going to tell you this stuff who who's going to tell you nobody right and so the only people that know these stories or want to talk about it are people who have nothing to lose. I am one of them right what really what do I have to lose now and others who have maybe left those groups and set up their independent practices that can tell you why they left. And so that is my end game for you guys which is to share more of that with you so that you know what it's like in all these different places and i'm not saying that everybody has to go in private practice or you see of course not. But I think you just have to know you have to know going into it what's involved because you guys can do things that you can you can argue your contracts you can reduce the distance of your non-compete you can just say no we are not doing that or you know some of the things that are happening will just blow your mind. And my hope is you guys will argue for more of what will make your job joyful and work well and if I can help with that i'm here for you guys. Absolutely no and you know thank you for everything that you're putting on all the content i know i've been learning a lot in like i'm going to say the intro this episode i think everyone needs to get a pen and paper to really take notes and and to learn and understand what's going on because i truly believe this is kind of the future. Of where medicines heading at least you know you talk about the business side of things the startup side of things people who are frustrated these are all valid points and i think that's a great way to ask you this question that we ask all our listeners is how do we add the health back in health care. Put the patient first. Put the patient first do whatever you need to put the patient first and i think that'll put the health back in health care naturally and it'll also bring the joy back love it. Well said thank you thank you lia thank you so much for having me guys and you know stay in touch and forward to collaborating with you guys in the future. Thank you for tuning in to another episode of medicine redefined. Now before that all important disclaimer a quick announcement as i mentioned before darshan i have had so much fun over the past few years creating content for you guys creating on some amazing guests and just building a large network but it comes with a lot of work and so we're happy to report that our team is continuing growing and so we're looking for a few motivated and driven individuals who are interested in working with us being part of the community and help us with some of the social media aspect but also with some of the technical aspects of what it takes to kind of put a podcast together and that might include audio video editing and so if you find yourself being skilled in those facets then you might be a good fit. Also you have to have an interest and you have to have a passion those are some of the prerequisites but what will you get out of it you might ask? Well aside from the obvious being part of a community the large network that was mentioned before in direct mentorship you get to be part of a team that's interested in adding help back to healthcare. If you've been a regular listener you know that we're extremely passionate about this and this is something we're going to continue to work on and so maybe we can do it together. We are accepting applications at this point and the best way to through your name and the pool is to shoot us an email with your CV and cover letter of why you think you'd be a good fit and what you might have to offer. The deadline for those submission is on the 23rd Sunday night ideally before 10 p.m. Eastern Center time and then shortly after that we'll be reaching out and talking about what the next steps will be. So the way to reach out to us of course with those things that I mentioned is directly at med redefined at chemo.com. We look forward to hearing from you hopefully work with you. Now the important disclaimer that everything in the podcast is for educational purposes only. It does not cost you the practice of medicine no should be considered as medical advice no physician patient relationship is formed and everything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health related issues. As always if you enjoy the show subscribe review share with anyone who you think will gain value and we'll catch you next time.