Latest / DPC Life: Direct Primary Care Podcast / When Is It Time to Leave the System for DPC? (with Dr. Sandra Koehn)

Transcript

When Is It Time to Leave the System for DPC? (with Dr. Sandra Koehn) · DPC Life: Direct Primary Care Podcast

• 0:00
  So I never ever, ever imagined in my life that I'd be opening
• 0:03
  my own practice. And then the straw that broke
• 0:05
  the camel's back was just like they were like, Yep, you can't
• 0:08
  take, you won't be able to take Christmas off because there's
• 0:10
  four of you and, and there and only one of you can be off.
• 0:14
  And like time with my family is so important.
• 0:17
  That is like where I drew the Winehouse came home that night
• 0:21
  and I was like, that's it. I have to leave this job.
• 0:24
  I can't take it anymore. So here we are jumping off the
• 0:27
  Cliff. We're ready to go.
• 0:29
  Welcome to DPC Life, the podcast where independent doctors share
• 0:33
  real stories, bold ideas, and the freedom of doing medicine on
• 0:37
  your own terms. I'm your host, Doctor Ann
• 0:41
  Gonzalez, and together we'll explore the winds, the
• 0:44
  struggles, and everything in between.
• 0:48
  Let's dive in. Welcome back to DPC Life, the
• 0:51
  podcast where we talk about all things DPC and life beyond the
• 0:55
  office. And my guest today is Doctor
• 0:58
  Sandra Keene. She is an internal medicine
• 1:01
  Doctor Who is getting ready to open her DPC planted DPC in
• 1:05
  Rochester, NY in just a couple of months.
• 1:08
  Together we talk about boundaries, talk about the ideal
• 1:12
  patient that she'd like to see, access to care, and how to build
• 1:17
  a DPC practice that helps both her patients and fits her own
• 1:20
  life. But before we dive in, if you
• 1:24
  are a woman in DPC or you're about to open your DPC and
• 1:29
  you're feeling a little bit stuck, scattered, or feeling
• 1:32
  alone in your journey, I'm hosting a small in person event
• 1:37
  in Hickory, NC next month called DPC Women Connect.
• 1:42
  It's capped at 15 women and designed for connection and
• 1:47
  support and not information overload.
• 1:50
  We want to provide a community to support you that you can come
• 1:55
  to when you need answers and just need someone to listen to
• 1:58
  and maybe a little bit of guidance.
• 2:00
  So you can find the details in the show notes below.
• 2:03
  So let's get into the episode with Doctor Sandra Keane.
• 2:06
  So today my guest is Doctor Sandra Keane.
• 2:09
  She is a direct primary care physician.
• 2:12
  About to be right, about to be direct primary care physician in
• 2:15
  Rochester, NY and her DPC is called planted DPC so welcome.
• 2:21
  Thank you. Thanks for having me on.
• 2:23
  I'm very excited. Absolutely.
• 2:25
  I'm glad to have you on. So let's start out.
• 2:28
  Tell us more about how you got into DPC and what you were
• 2:32
  looking for when you came to DPC.
• 2:35
  Yeah. So I never ever, ever imagined
• 2:37
  in my life that I'd be opening my own practice to meet.
• 2:40
  I'm like, I don't have a business sense.
• 2:41
  I'm this is not a thing I want to do.
• 2:43
  I just want to go take care of patients, come home and like we
• 2:47
  work at the job. And so, yeah, it was never
• 2:50
  anything on my radar. And the first time I heard about
• 2:52
  DPC was probably around 2020. My husband, who's also a
• 2:55
  physician, and I knew a couple in residency who opened ADPC
• 3:00
  together out in Michigan. And so that was the first time
• 3:04
  I'd ever heard of it. And we kind of looked into it
• 3:05
  briefly and we were like, what is this crazy direct care thing
• 3:08
  like this sounds, it was like too much for us at the time.
• 3:10
  We're like, kind of sounds nice to be your own boss, But this is
• 3:12
  just not, no, our job's OK, we're surviving.
• 3:15
  It's fine, not for us. And then just, I think after the
• 3:18
  pandemic, our, I've been an employed physician for about 7
• 3:22
  years. And when I first signed on, it
• 3:24
  was all of our higher administration was all
• 3:26
  physicians. It was really physician
• 3:28
  friendly. It really, there were a lot of
• 3:30
  just the way they treated us just really was what kind of
• 3:33
  drew us to move to Rochester where we like don't have any
• 3:37
  family. I mean, we're just, we came here
• 3:38
  just like for this job basically.
• 3:40
  And, and just since COVID, just the whole upper administration
• 3:45
  framework has completely shifted out with the old in with the
• 3:49
  new. And it's just been such a
• 3:51
  massive overhaul that it's just become so corporate.
• 3:54
  And just over the last several years, we've just seen our
• 3:59
  autonomy just dwindle and micromanagement kind of
• 4:05
  increase. And they're like becoming very
• 4:07
  just trying to kind of squeeze blood from a stone every little
• 4:10
  like you're 15 minutes short on your contact hours.
• 4:12
  You got to add like an appointment here.
• 4:14
  You can't block this or your lunch now doesn't count towards
• 4:17
  your hours where it's like, who even has lunch?
• 4:19
  We're seeing patients. And so, yeah, I think that's
• 4:24
  funny. And then the straw that broke
• 4:26
  the camel's back, which there had been like a few things in a
• 4:28
  row where like they told me I couldn't have a Med student and
• 4:32
  because we were too busy, I was like, you're telling me I have
• 4:34
  to wait? What?
• 4:35
  But no. Yeah.
• 4:36
  So and then the straw that broke the camel's back was just like
• 4:38
  they were like, Yep, you can't take, you won't be able to take
• 4:41
  Christmas off because there's four of you and and there and
• 4:45
  only one of you can be off. And I have three very small
• 4:48
  children and my husband, like works every other Christmas
• 4:51
  holiday. And I'm like, well, the perk of
• 4:54
  staying where I was is between the other doc and I, we were
• 4:57
  pretty good. I would take Christmas every
• 4:59
  year, She'd take Thanksgiving every year.
• 5:00
  And it like worked out really well.
• 5:02
  And I had thought about transferring to a different
• 5:04
  office within the organization, but that was like the thing they
• 5:06
  were like, you might not be able to get all the holidays you want
• 5:08
  because everybody else has got little kids too.
• 5:10
  And, and so it was kind of like, all right, I'll just stay.
• 5:13
  And then all of a sudden everything changed and Nope, you
• 5:16
  can't have the holiday off and no, you can't have this time
• 5:19
  off. And and like time with my family
• 5:21
  is so important. That is like where I drew the
• 5:25
  Winehouse. I came home that night and I was
• 5:27
  like, that's it. I have to leave this job.
• 5:30
  I can't take it anymore. We got to find some different
• 5:33
  way because this is that's it. So we kind of talked about it,
• 5:37
  and my sweet husband is very supportive.
• 5:39
  And he's like, he's like, OK, well, let's look into this whole
• 5:43
  direct care thing again. Yeah.
• 5:44
  And then, I don't know, just for whatever reason, this time we
• 5:46
  looked at it and more seriously and kind of started reaching out
• 5:49
  to local DPCS, which we have a handful of them now in the
• 5:53
  Rochester area. And just the more we, like, dove
• 5:57
  into it and the more we learned about it, I was like, oh, my
• 5:59
  gosh, this, this is the thing. Like, this is the calling.
• 6:02
  This is what I want. And so.
• 6:04
  Yeah. So here we are jumping off the
• 6:06
  Cliff. We're ready to go.
• 6:07
  Yeah. It is like jumping off a Cliff,
• 6:12
  but it's all good. It's all good.
• 6:13
  So your practice that you you're out now, correct, You're done
• 6:18
  with your employed. No, I'm still actually there.
• 6:22
  I have given my notice so my last day so I'm working through
• 6:25
  the end of February. So have let's see, do you have a
• 6:29
  non compete? Yes, so I do, I've got like a 10
• 6:32
  mile non compete, which is fine because I work like 20 miles
• 6:35
  from where we live. So it'll actually work out.
• 6:39
  So I've got a location already, which is like a small, like a
• 6:42
  little crew that I'm gonna be renting like month to month.
• 6:46
  And yeah, my and then I do have a one year non solicit, which I
• 6:49
  think most contracts have that maybe I don't know.
• 6:53
  And so I'm not like, are you technically able to tell anybody
• 6:57
  like where I'm going or what I'm doing?
• 7:00
  And it's just super awkward cuz patients are rescheduled.
• 7:03
  They're like, okay, well see you in three months.
• 7:05
  And then they go out and they're like, well, why are we scheduled
• 7:07
  with the NP? They'll be like, well, she's not
• 7:08
  here that day. Well then we'll just wait till
• 7:09
  she comes back. And it's just like super
• 7:13
  awkward, so weird. Never coming back?
• 7:16
  No. I don't know.
• 7:17
  I don't know what they're doing. I'm just like, OK, you don't
• 7:19
  want me to say anything. I'm not going to say anything,
• 7:21
  but this is making y'all look bad.
• 7:22
  No, I mean. So they haven't told your
• 7:25
  patients? No, they haven't really told you
• 7:27
  when I was kind of like, hey, people are asking what do you
• 7:30
  want us to say? They're like, well, we're
• 7:31
  planning on sending a letter 6030 to 60 days prior to your
• 7:35
  last day. I'm like, well, that's really.
• 7:39
  That's still a while. It's gonna be, yeah, So I don't
• 7:43
  know. I'm like, OK, But I mean, I have
• 7:47
  a landing page which I've been kind of working on.
• 7:49
  So since I decided to do this DPC thing, before I even put in
• 7:52
  my notice, I created a landing page.
• 7:54
  I was kind of just doing like A blog and it was just health
• 7:57
  resources. I kind of just framed it as
• 7:59
  helping tests for my patients. And so if I had a patient coming
• 8:02
  in, we're talking about nutrition or they have
• 8:03
  hypertension or diabetes and we're talking about I'll say,
• 8:06
  hey, check out this. It's all the stuff we just
• 8:08
  talked about. But if you forget everything I
• 8:10
  just said, it's all oh, that's. Great.
• 8:12
  In there and so I've had patients kind of looking at
• 8:15
  that. And so I initially I was kind of
• 8:18
  like I had AQR code and I was like, hey, look, check this out.
• 8:21
  And and then I had a patient come in just a week or two ago
• 8:23
  and she said, hey, I was just looking you up and I found this
• 8:26
  like page and she found it on her own.
• 8:29
  And I was like, that's so exciting.
• 8:30
  So, so I know people will find it.
• 8:32
  And so I'm hoping once the news is out there and I can actually
• 8:35
  be open and talk about it, but I'll put something on there or
• 8:40
  maybe even forward that to my website, my clinic website once.
• 8:43
  Yeah, that's launched. Yeah, perfect, Yeah.
• 8:46
  Do you have a sign up to get emails on your blog?
• 8:51
  So I kind of tried to do that and I'm having trouble with the
• 8:55
  techie part of it. It's just like I can't get it to
• 8:59
  work. Initially I did have that and it
• 9:02
  was like sending, I wanted to set it up so it would send a
• 9:07
  welcome e-mail or something or an alert.
• 9:09
  But then the automation thing wasn't working and I was going
• 9:13
  to spam and like it and I was kind of just, I'm doing so much
• 9:16
  other stuff right now. I just don't have live band
• 9:19
  account. So I kind of just aborted
• 9:21
  mission with that a little bit. Well, you could do it the old
• 9:25
  fashioned way and just have them write their e-mail down and say,
• 9:29
  hey, I've got this newsletter that or this blog where the
• 9:34
  stuff we just talked about I. Will.
• 9:38
  So they add you to the list, writing their e-mail?
• 9:40
  Yeah. You're not soliciting them, OK.
• 9:44
  You're just getting information for an e-mail.
• 9:46
  Yeah, yeah, OK. Oh, that?
• 9:49
  Well, that's. And then very simple, I could do
• 9:51
  that. I can do that.
• 9:55
  You can do this. You got this.
• 9:58
  You got through medical school and residency, you got this.
• 10:00
  I feel like I'm at a point now where initially it was all just
• 10:03
  a medicine. Part of it was so overwhelming
• 10:05
  and I was like, I can't even handle thinking about a business
• 10:08
  thing too. I'm just trying to learn the
• 10:10
  medicine of it all. I mean, not to say, I mean,
• 10:13
  there's lots of things I still don't know, but I'm, I'm more
• 10:15
  comfortable with all the medicine piece of it.
• 10:18
  And so I'm like, OK, now what? So this has been really, yeah,
• 10:23
  like exciting. Like I'm so like energized and
• 10:26
  so excited. I'm learning all sorts of new
• 10:27
  things. I like never really honestly had
• 10:29
  an interest in well. Good.
• 10:31
  Yeah, that's great. Some people do it and they
• 10:33
  don't, they really don't enjoy the business part.
• 10:35
  I mean, they're like, well, they have to do it, so they do it.
• 10:37
  But it is a lot easier if you do like it.
• 10:41
  The marketing stuff is really cool, but I don't know, like the
• 10:43
  financial thing is still not like my thing, but I haven't
• 10:46
  gotten super into that yet. But it's been fun.
• 10:48
  Just like learning new things and it's and just being like
• 10:51
  being creative and just like creating something is, is just
• 10:54
  really, really fun. Yeah, Yeah.
• 10:56
  I think that's one thing that a lot of business owners and
• 11:00
  physicians that are entrepreneurs as well, they
• 11:02
  realize that they are creative people and there's really not a
• 11:05
  great outlet for that within medicine itself.
• 11:09
  People do stuff outside of medicine, but then this way it
• 11:12
  is creating, you're creating your own business, you're
• 11:14
  creating what your dream. So it is very much creative.
• 11:18
  Well, let's see, what would you like to focus on?
• 11:22
  So after we talk, after the end of this session, what would make
• 11:27
  it successful for you if you had walked away with some kind of
• 11:30
  plan? So I have two or three kind of
• 11:34
  areas. So 1 is a smaller maybe quick
• 11:39
  like what's your opinion type of question.
• 11:40
  So I'm a DO and I do osteopathic manipulative medicine and I do
• 11:44
  some of that in my current employee job now.
• 11:48
  But not, I don't really advertise it cuz it's just time
• 11:50
  consuming and I just honestly can't do a lot of it.
• 11:53
  But I'm really hoping to incorporate that within my DPC.
• 11:56
  And so I've gotten a lot, I've gone back and forth a lot on
• 12:00
  should it just be something for members or should it be
• 12:03
  something that I offer for non members as potentially like a
• 12:07
  way to get them in the door? I'm sort of leaning towards that
• 12:11
  option. And there really are not a lot
• 12:13
  of other osteopaths in the area that do this.
• 12:16
  So I think there is a market for it.
• 12:19
  And so I was thinking of offering OMM to non members at
• 12:25
  just like a per treatment, you know price and then they can
• 12:28
  have a much discounted rate if you are a member and you do want
• 12:31
  some OM treatment. So I don't know kind of what
• 12:34
  your thoughts on that. Yeah, I think that's something
• 12:37
  especially for people who are starting out, several docs that
• 12:40
  I know have used that as kind of their initial draw for patients
• 12:45
  and they'll start out with non members.
• 12:48
  And just like you said, say for example, it's 150 for a non
• 12:51
  member, it's 125 for a member. So you're not undervaluing it,
• 12:55
  you're not going to completely cut it to 60 bucks.
• 12:57
  But there is a benefit to being a member.
• 13:02
  I have talked with one physician who said he was doing a lot of
• 13:06
  it, but he cut back because he realized he was like, you know
• 13:09
  what, my hands, I had a hard time doing all the OMTI was
• 13:13
  actually getting very tired. So he was doing a lot more.
• 13:17
  But once he got busier, he kind of slowed down on it because
• 13:21
  just physically it was difficult.
• 13:24
  But yeah, I think that's a, it's a great thing to be able to
• 13:27
  offer and it is definitely different.
• 13:29
  I think D OS are it's they don't get a chance to do OMTA whole
• 13:34
  lot just within the system because everything is so time
• 13:38
  crunched. You need time to do that.
• 13:42
  And there really isn't any. Chance to So if you enjoyed the
• 13:45
  OMT, which it sounds like you do, this is great.
• 13:48
  You get to bring back those skills, you got to use them.
• 13:50
  Awesome. So you said something about not
• 13:52
  undervaluing it. So I was actually gonna be, I
• 13:54
  was thinking of doing 150 for a non member.
• 13:57
  I was actually gonna do like 50 for a member.
• 14:00
  Is that just too, too low? I guess I was kind of trying to
• 14:04
  with if you have the membership plus that like I wanted to make
• 14:07
  it so that it's almost a no brainer to like just do the
• 14:10
  membership. But I don't know.
• 14:13
  Yeah, Yeah. No, I think there's definitely a
• 14:15
  point to that. If you do it at 40 or 50, you're
• 14:20
  going to have a lot and depends on what you want.
• 14:25
  If you want more than keep it lower.
• 14:26
  If you don't want as much but you want some, OK, I keep it a
• 14:29
  little higher. That's helpful.
• 14:32
  So my other question is, well, my big question is about my
• 14:37
  patient, the ideal, the ideal patient that that question just
• 14:41
  always gets me because I'm like, I like all sorts of people.
• 14:45
  So I've had a hard time narrowing it down.
• 14:47
  And I think they do tend to be more women, but I have a lot of
• 14:50
  male patients that I also like enjoy interacting with and
• 14:53
  treating. They tend to be sort of in the
• 14:57
  kind of younger to like middle age, like maybe 30s, forties,
• 15:02
  maybe 50s too. And typically, you know, just
• 15:06
  busy professionals have a lot of demands on their time.
• 15:10
  They're taking care of their kids, maybe they're taking care
• 15:12
  of aging parents. They're working a full time or
• 15:15
  part time job. Well, it is hard.
• 15:17
  I mean, primary care is not specialized, obviously.
• 15:20
  I mean that's the complete opposite of it.
• 15:22
  So it is hard to pick one, of course, but you enjoy
• 15:25
  relationship medicine. It's very obvious you like the
• 15:28
  relationships with your patients.
• 15:30
  And I think I mentioned in an e-mail, I said, well, who's your
• 15:32
  favorite patient? Think of who your favorite
• 15:35
  patient is or like a couple different favorite patients that
• 15:38
  you like to see. When you see their name on your
• 15:40
  schedule, you're like, yes, I'm going to see so.
• 15:42
  And Saturday I'm excited about that as opposed to some people
• 15:45
  you look at the schedule and you're just like sad before I go
• 15:48
  in there. Yeah.
• 15:52
  So yeah. Who is that one or two people
• 15:56
  that you enjoy seeing? And then what is it about them
• 16:00
  that you enjoy? Why do you enjoy seeing them?
• 16:04
  And then most of the time, though, it is, like you said,
• 16:06
  mostly women and the people that are kind of similar to your age.
• 16:10
  That's what most people enjoy seeing anyway, right?
• 16:14
  Yeah. Because if someone is 70, they
• 16:17
  really don't love seeing a 30 year old who just got out of
• 16:19
  residency, right? But yeah, which is fair.
• 16:24
  I mean, some do you do build better connections with people
• 16:27
  that you can empathize with, So that makes sense.
• 16:31
  And then as you continue in your career, your patients kind of
• 16:34
  age with you. It's just pretty typical.
• 16:37
  But yeah, So what would you say? What are the OK people?
• 16:43
  You know, those people that you like, those favorite?
• 16:45
  Patients, OK, I would say in like early 40s and like thinking
• 16:51
  of a person in particular who she is a therapist.
• 16:54
  She owns her own therapy kind of business.
• 16:57
  Her husband sees me as well and he's in education.
• 17:00
  They have two younger kids, not like super young.
• 17:04
  They're like school age children doing like a lot of sports and
• 17:07
  that kind of thing. I, I think I enjoy seeing her
• 17:11
  just because of we just kind of have a rapport.
• 17:13
  I think we're very kind of comfortable talking about just
• 17:16
  all things, not just medicine, but like how is life going and
• 17:19
  all of that, all the family dynamics and everything and just
• 17:24
  very just kind of health conscious.
• 17:27
  Like she wants to stay healthy and but is there's a fine line
• 17:33
  there because like when it gets to be like too much, well, it
• 17:37
  gets, it can sometimes be a lot where they want a lot of
• 17:40
  different things that are maybe not super evidence based or
• 17:45
  that's not the person. So that can go wrong very
• 17:47
  quickly. But I don't know, I think I
• 17:49
  actually realized I like seeing patients who have not like
• 17:55
  debilitating anxiety. That can be really kind of
• 17:57
  frustrating if you keep trying to help them and that nothing's
• 18:00
  working. But I do kind of like seeing
• 18:01
  patients that are like super overwhelmed and they're very
• 18:04
  busy and they're not sleeping and, and, and doing some stress
• 18:06
  management stuff with them and helping like with same anxiety,
• 18:10
  maybe with medication or therapy or some other kind of lifestyle
• 18:13
  things. And then just seeing those
• 18:15
  people back and seeing them improve and they're just always
• 18:18
  so grateful. And I love that.
• 18:19
  I think that's super rewarding. But I also have these like super
• 18:22
  cute old ladies that I love seeing too.
• 18:25
  I mean, but I think it's mostly your like you said, people that
• 18:28
  are similar kind of stage in life as I am.
• 18:32
  OK. I mean, yes, we, we like seeing,
• 18:36
  that's why we went to primary care.
• 18:37
  We like seeing the spectrum. So think about that, the
• 18:41
  therapist that you were just talking about.
• 18:43
  And so where does she hang out? Does she go to the gym?
• 18:49
  Does she have elementary school kids?
• 18:51
  Does she shop at Target? Does she like, what does she do?
• 18:55
  And where would you be able to find other people like her?
• 18:59
  OK OK so trying to find some of those answers so that you can.
• 19:06
  Yeah. And you can, I mean, you just
• 19:08
  you can. It doesn't have to be a real
• 19:09
  person. I mean, you don't have to base
• 19:11
  it on her particularly, but you can say, OK, yeah.
• 19:13
  So my ideal patient is in her 40s.
• 19:16
  Her kids are like in elementary and maybe middle school.
• 19:19
  They're real busy. They got soccer and baseball.
• 19:23
  And she's traveling all over the place.
• 19:24
  And she is working, too. And her parents are getting a
• 19:27
  little older, so she's taking care of them, too.
• 19:28
  And so then you kind of figure out, well, where does she go?
• 19:31
  What kind of circles? And then where can you meet
• 19:35
  people like her? OK, OK.
• 19:40
  So then once you do kind of hone in on that app that perfect
• 19:43
  that, you know your perfect patient, then what's like the
• 19:47
  next step in that progression? So yes, let's say she likes to
• 19:51
  go to Starbucks every day and she take travels for soccer.
• 19:54
  And so she's very busy and does a lot of, I don't know, instant
• 19:59
  writing. I don't know.
• 20:04
  Yeah. So then try and think about, OK,
• 20:06
  put yourself in her position, what are her pain points
• 20:08
  regarding medicine, the health system, is it access?
• 20:13
  Is it the short visits really is difficult for her?
• 20:17
  Can is she not seeing her same, but she not going to see her
• 20:20
  doctor because say you're booked out two months.
• 20:24
  Is she getting short visits because again, you're seeing 30
• 20:28
  people a day? Is she not going to have the
• 20:30
  time to discuss what she needs to discuss?
• 20:33
  Is there time to talk about mental health the way that you
• 20:36
  want to address it? Right?
• 20:38
  So kind of putting yourself in her place.
• 20:41
  I mean, you can and you can even ask your patients now if there
• 20:45
  was an ideal practice. What would it look like?
• 20:48
  What would you want? Yeah.
• 20:49
  So I kind of some part of our local kind of mom's group for
• 20:53
  for our little town and and anytime kind of something
• 20:57
  medical comes up. What kind of hey, basically,
• 21:00
  sure, is what I think. Maybe talk to your doctor.
• 21:02
  Good, whatever. And so I put out this poll once.
• 21:05
  Just what? I'm a primary care doc in the
• 21:08
  community. What about our system?
• 21:11
  What about the healthcare system is the most frustrating for you?
• 21:14
  What irks you? What would you want to change?
• 21:17
  And just by I was, so I was amazed that actually the
• 21:19
  responses like there were, I think there were like 100 people
• 21:23
  who commented on it, which was like wild.
• 21:26
  So it was and they were all like, thank you for asking.
• 21:29
  They were just so like grateful that somebody was actually
• 21:31
  asking them what they think, which was really surprising to
• 21:34
  me. But by and large, I would say 80
• 21:37
  to 90% of people struggled with access.
• 21:39
  It was just access, access, access.
• 21:42
  I mean, there were other things here and there, but that was the
• 21:45
  one kind of main thing that just kind of kept coming up.
• 21:48
  And and so that after I did that, I sort of reframed like I
• 21:52
  went back and because I was working on my website at the
• 21:54
  time and I sort of went back and changed some things to really
• 21:57
  try to bring out that to kind of address that pinpoint the most.
• 22:01
  A great idea to do the poll? Absolutely.
• 22:05
  So that was super helpful. But yeah, I think a lot of
• 22:07
  patients in our particular area just really struggled to get in
• 22:10
  to see their doctor or even to get to have an established care
• 22:14
  with a primary care doc. Yeah, could take six months to
• 22:17
  get in. And then I've had this happen to
• 22:20
  patients before. They wait six months.
• 22:23
  By the time they get there, the doctor they were going to see is
• 22:25
  gone. They're sleeping yet?
• 22:27
  So they have to see someone else.
• 22:29
  Isn't that terrible? So sad.
• 22:31
  Or they see them one time and then they're.
• 22:33
  Gone. I know.
• 22:34
  And then they're gone. Yeah.
• 22:35
  It's terrible. Yeah, it is.
• 22:37
  Yeah. But that's that's really a great
• 22:40
  idea. So those people who did respond
• 22:42
  to you, if you know any of them and you feel comfortable talking
• 22:45
  with them, you can reach back out to them and say, hey, you
• 22:48
  answered my poll. Can I pick your brain?
• 22:51
  And, and odds are if they're responding to your poll,
• 22:55
  they're, they're pretty irked about something, something
• 23:01
  they've got a bone to pick about something.
• 23:03
  So reaching back out to them and just kind of getting a feel.
• 23:06
  And then you can also can start saying, I mean, if you're
• 23:09
  allowed to say stuff, talk about the DPC, just kind of start
• 23:12
  putting that bug in their ear because some of these people
• 23:16
  could help spread the word for you.
• 23:18
  And the groups can be really, they can be really helpful
• 23:21
  because if you can find a couple people who are either your
• 23:25
  patients or you know them and they can vouch for you because
• 23:28
  there's always somebody on those groups.
• 23:30
  Hey, who's a good doctor? My doctor doesn't listen.
• 23:33
  I mean, it's every day there's something on these groups.
• 23:36
  Then whoever can say, well, yeah, what about Doctor King?
• 23:41
  But she's got a new practice. She's taking patients.
• 23:44
  And especially if they are your patient, then that's really nice
• 23:47
  because then they can, they can talk, talk about the practice.
• 23:50
  Yeah. And say what they like about it.
• 23:53
  So the groups are great. So and then also if somebody
• 23:56
  asks a question, certainly you don't want to give medical
• 23:59
  advice. You can just kind of educate,
• 24:03
  say I'm a physician, I'm a pregnant physician.
• 24:09
  I mean, no medical advice, of course.
• 24:11
  But then if you're interested in coming to see me, there's a lot
• 24:15
  of them. You can't just put out an like
• 24:17
  an advertising or promotional post, but you can if someone
• 24:20
  asks a question, generally it's OK at that point to say I have a
• 24:26
  practice. Yeah.
• 24:28
  OK. But yeah, just check the rules
• 24:30
  of the groups you don't want to get booted out.
• 24:32
  But generally that seems to be how they most of them are.
• 24:36
  OK. OK.
• 24:38
  My next question for you is about boundaries.
• 24:44
  I did. I think it was.
• 24:45
  You had done an episode on boundaries.
• 24:48
  Maybe. I think yeah.
• 24:49
  With Doctor Cook, yes. Yes.
• 24:51
  And so I was like, oh man, I need those so bad.
• 24:54
  Just even start. I'm not even, I haven't even
• 24:56
  launched my DPC yet. And I'm already like thinking
• 24:59
  about it like at all hours of the day and night.
• 25:02
  And I can. And I listened to that episode
• 25:03
  and I was like, Oh yeah, I need this.
• 25:05
  And so I really like, and you've said this a few times and I love
• 25:08
  your podcast, by the way. I've listened to all your
• 25:09
  episodes so far. They're so sweet.
• 25:10
  It's. So good.
• 25:12
  And that's why I saw her. You're like anybody want.
• 25:14
  I was like, yes, me, pick me. So just like the starting how
• 25:18
  you want to finish that like really spoke to me.
• 25:22
  I love that because I was like, Oh yeah, I'll have so much time.
• 25:24
  But you're right. Then you set this precedent and
• 25:27
  then you can't keep that up. And so I guess I'm not really
• 25:33
  sure exactly what my question is.
• 25:34
  I I still want to be able to like have time for my kids.
• 25:37
  Like I have to, you know, drop them off, pick them up from the
• 25:40
  bus. I've got my kids are like 7-5
• 25:43
  and two, so they're, they can, they're a lot after 334 when
• 25:49
  everybody's home and I'm like juggling all of that stuff.
• 25:52
  It would be difficult at that time to be answering patient
• 25:55
  calls and having a long discussion over the phone with
• 25:58
  someone. And so I guess I'm not sure how
• 26:04
  in my mind, I'm kind of like part of our value my whatever I
• 26:08
  see the value proposition of DPC is we're available whenever you
• 26:11
  need us. And so I'm having a hard time
• 26:14
  like bringing that with, well, I can't really talk to you after
• 26:19
  four unless you like, really need me.
• 26:21
  So how do you do that? Is that fair?
• 26:24
  Will patients kind of scoff at that and say, well, why am I
• 26:27
  paying if you're not available at all hours of the day and
• 26:31
  night? I don't know what your
• 26:33
  experience has been or any advice you can lend to that.
• 26:37
  Yeah, it's, it's tough. And there are a lot of women in
• 26:42
  similar situations, very young children, they work part time
• 26:46
  because they are the main caregivers for their children.
• 26:49
  And so you have, it just goes back to you got to start the way
• 26:54
  you want to finish. So you go in with having kind of
• 26:58
  the expectations, going through those expectations with your
• 27:02
  patients so that they understand I am a mom, I'm a mom first,
• 27:08
  right. And my family will always come
• 27:11
  first. Not that I don't care about you,
• 27:12
  but yes, like they come first. And so there will be times where
• 27:16
  I might not be able to see you. I might have to reschedule
• 27:19
  because my little one's sick or I have to pick them up after
• 27:23
  school. So if you start out by telling
• 27:27
  people this is how it is, I'm in the office Monday, Tuesday,
• 27:31
  Thursday from 9:00 to 3:00 or whatever your schedule is, then
• 27:38
  if they're your people, they will respect that boundary and
• 27:43
  they will understand when you say I can or I can't do this.
• 27:47
  You have to set the expectations up front.
• 27:50
  I mean, you're there to serve them, yes, but you also want to
• 27:53
  protect your time, protect your time with your family.
• 27:55
  So the boundaries, it is hard. And one thing, I think it was at
• 28:00
  one of the DPC summits, maybe Doctor Cloto Ryan, she was
• 28:04
  giving a talk about boundaries and she was saying that if
• 28:07
  there's something that's happening and you are starting
• 28:09
  to feel resentful, Oh my gosh, that patient called again.
• 28:12
  I can't believe it. There's a boundary being crossed
• 28:15
  and you need to figure out, maybe you don't even know what
• 28:18
  boundary it is. But if it's getting on your
• 28:20
  nerves, something's happening and you need to kind of
• 28:24
  backtrack and figure out, well, is this something that I've told
• 28:28
  them not to do? Because if it is, then they've
• 28:31
  definitely crossed a boundary. But if you haven't said anything
• 28:33
  about it before, then that's on you.
• 28:36
  You need to clarify with them. This is not acceptable.
• 28:39
  Yeah. This is not how it works.
• 28:40
  Yeah. So it's, it's also about, yeah,
• 28:44
  sensing. How do you feel about that?
• 28:46
  Because there will be times where you're like, Oh my gosh, I
• 28:48
  can't believe that they're asking for this again.
• 28:51
  And sometimes it's because we hadn't said this is what you
• 28:56
  need to do or yeah, this is how it works.
• 28:58
  And so we just then, then we know, OK, we need to add that to
• 29:03
  our list of the if this happens, this is what you do.
• 29:06
  Coming back to boundaries is is it unheard of?
• 29:11
  So I have friends who they're like you're on call.
• 29:14
  What my doctor doesn't take calls like on weekends.
• 29:18
  I'm like, is that a thing I. Didn't think you could do that.
• 29:20
  I didn't think you could do. That so I was going to ask you,
• 29:24
  can I just be like. There has to be somebody like on
• 29:26
  Sundays or some I'm not. Going to answer the phone.
• 29:29
  So get you things needed, you know, whatever you need.
• 29:31
  And if you need to go to urgent care, then go to urgent care.
• 29:33
  You can wait for me on Monday. Like is that like too much of
• 29:36
  about? Can you do that?
• 29:37
  I don't know. For some reason I'm thinking
• 29:38
  that you have to have at least something all the time.
• 29:42
  I'm not sure why that's in my head.
• 29:43
  But when you think about access, you can have certainly phone,
• 29:49
  you can have text, you can have portal.
• 29:51
  So if you have, I mean, you can certainly say I'm not answering
• 29:57
  just routines. I'm not doing your refill on a
• 30:00
  Saturday because you forgot. That's one of the things we say
• 30:04
  please don't wait until the weekend.
• 30:06
  If you need an appointment, don't call me on Sunday morning.
• 30:11
  Let's do that on Monday. So you can, you can say please,
• 30:15
  I will answer urgent calls on the weekends.
• 30:18
  And generally, I'll say it's not very often, OK, I think
• 30:23
  patients, they'd like to know that you're there for them.
• 30:27
  And some people have this situation where people are
• 30:29
  calling, calling, calling, calling, and it's just, they
• 30:31
  just need to know that you're there for them.
• 30:33
  They're not going to get ghosted when they need you.
• 30:36
  You will be there and then they start to calm down.
• 30:39
  But yeah, I think definitely still saying I will answer your
• 30:42
  calls if it's something and we'd use the portal for this a lot.
• 30:46
  So if it's something that's not urgent, please just put in the
• 30:50
  portal. And again, like that way I don't
• 30:51
  see it and obsess about it. The thing is, it's very, it's
• 30:57
  very freeing because you're the boss and you can kind of make
• 31:01
  the rules, right? I mean, not kind of you can.
• 31:04
  These are your rules. These are your rules.
• 31:05
  So a lot of times, just like you're saying, do people do
• 31:09
  that? I mean, you don't have to get
• 31:10
  permission from anyone because you're the boss.
• 31:13
  Then you can design your practice the way you want it.
• 31:16
  Yeah, I know we're kind of running a little bit short on
• 31:18
  time, but my last question is, So here in New York, we have a
• 31:21
  lot of DPC is complicated out here.
• 31:25
  Not as yeah, I've heard. Unfortunately, we can't do like
• 31:30
  in house dispensing. We just can't.
• 31:33
  It's all patient direct billing for labs.
• 31:35
  So we can't do client build labs.
• 31:36
  So we can't offer the three dollar A1C that I would so much
• 31:40
  love to offer. It's just so infuriating.
• 31:43
  And so I struggle a little bit to I just feel like it takes
• 31:47
  away some of that value of how great DPC can be.
• 31:52
  I don't like it just kind of it just feels like it takes away
• 31:55
  something. And so how do I still kind of
• 31:57
  offer value and sell, not sell DPC, but like how do I promote
• 32:03
  DPC and when two of these really kind of big benefits that a lot
• 32:07
  of people might read about are not really applicable here in
• 32:11
  our state? Yeah.
• 32:13
  Well remember most people don't know what DPC is anyway.
• 32:17
  That's true. So they may not know, yeah, that
• 32:20
  they could get client build labs or you know, in house dispensing
• 32:25
  meds. They may not even know that.
• 32:28
  Yeah. So it may be a non issue.
• 32:31
  It might, yeah. But that's true because if you
• 32:36
  are there DPCS in Rochester, I'm not sure, I'm not familiar.
• 32:40
  Yeah, a handful. Of that, a handful.
• 32:41
  OK, All right. So there's probably people who
• 32:44
  already know about DPC, but again, they're all still in New
• 32:47
  York, they're in the same area. So most people still don't
• 32:50
  realize that that's what's done in other DPCS unless they really
• 32:54
  start going digging around about DPC, they wouldn't know.
• 32:57
  So, but you're a do. So again, you've got the OMT,
• 33:03
  which is something that a lot of people don't do.
• 33:06
  And the other thing, think about the pain points that those
• 33:11
  people were talking about, access and time.
• 33:14
  Those are the biggest things that most, most people want.
• 33:18
  And that's very valuable because you know that it's very
• 33:22
  difficult to access the system, the regular fee for service
• 33:27
  offices and they don't get the time.
• 33:30
  So that's I think that's very valuable right there.
• 33:34
  And if people don't understand that that's OK, then they're
• 33:38
  probably not a good fit for you. Yeah, Yeah.
• 33:41
  And you don't need 2000. Yeah, right.
• 33:44
  You you probably want somewhere in 3 or 400 at the most.
• 33:47
  Right. Very, very much, yeah.
• 33:49
  So yeah, it's OK that they don't know that, and a lot they don't
• 33:54
  know about meds people. In our area, I've heard of
• 33:55
  concierge. So you know, you get the oh,
• 33:58
  here you go in concierge. What was that concierge And it
• 34:01
  just it has this and I'm sure you probably get that you know
• 34:04
  where you are too. It just has this connotation of
• 34:07
  like nose up in the air and I can't afford.
• 34:10
  They just kind of write it off sometimes as, oh, this isn't for
• 34:13
  me, this is concierge. This is for like only the really
• 34:17
  wealthy people, and that's not me.
• 34:18
  And so how do you kind of overcome that?
• 34:22
  No, this is for you. Like this is like affordable
• 34:25
  concierge. This is like concierge level
• 34:28
  care, but it's for the everyday person.
• 34:31
  How do you kind of break that misconception?
• 34:36
  Some people get very upset and briskly about it, and some
• 34:42
  people lean into it because the concept is difficult to
• 34:46
  understand. But people understand concierge,
• 34:50
  right? So some people will just be
• 34:52
  like, yeah, I call it concierge. It's not, but I call it
• 34:56
  concierge because then they don't have to worry about trying
• 34:58
  to explain the difference. But sometimes you can describe
• 35:02
  it. It's kind of like you just said,
• 35:03
  concierge, concierge level care for the everyday person.
• 35:08
  I mean, that's perfect. It explains it quite well.
• 35:12
  And so you can just say something like that or you can
• 35:16
  people call it blue collar concierge, concierge for the
• 35:19
  common people. And yeah, I think that phrase is
• 35:23
  really quite nice. It really describes it very
• 35:24
  nicely. So you can.
• 35:26
  Just explain what it's kind. Of like it because it's true.
• 35:28
  I mean, concierge is smaller patient panels, more time.
• 35:34
  It is kind of like it, right? But it's just the payment is
• 35:37
  different. So it's not necessarily a bad
• 35:40
  thing because it's already understood what it is.
• 35:44
  So you just kind of have to massage a little bit.
• 35:48
  It's just kind of finesse the finer points.
• 35:51
  I used to kind of get a little bit like not upset, but just
• 35:55
  kind of like it's not, it's not, it's not going to here.
• 36:00
  No, heck no, no. But now I realize that that's
• 36:04
  just that's just what people understand.
• 36:07
  And so kind of go from there. You take that start from there
• 36:10
  and then try to explain it. Makes sense.
• 36:14
  All right. I do have one last one if we
• 36:16
  have time. So I initially was going to take
• 36:21
  like the less risky kind of route of not opting out of
• 36:24
  Medicare right away. I was going to stay opted in and
• 36:29
  just do the thing like the wait list thing.
• 36:31
  And that way I could have like a side gig if I needed to.
• 36:35
  And then people that I've spoken to that might be interested and
• 36:39
  I'll be like, oh, yeah, can I join?
• 36:41
  And oh, we'll do take Medicare. And I've had a few patients be
• 36:43
  like, oh, my doctor, my dad would love this, but oh, no, but
• 36:46
  he's on Medicare. And it seemed like it was almost
• 36:49
  like a barrier to a lot of people when I really thought
• 36:52
  about it. I don't think a lot of them will
• 36:54
  come back in maybe six months, be like, now I can sign up.
• 36:58
  And so now I'm thinking maybe I should just I opt out right
• 37:02
  away. And then that way when I move, I
• 37:04
  mean, I'm, I already have a pretty large established panel
• 37:08
  who I think a decent number may actually want to follow me.
• 37:12
  And I think that opting out early might actually be a
• 37:17
  potentially a better option. So I'm not putting like a
• 37:20
  barrier there. But yeah, it also kind of seems
• 37:25
  OK. I don't have a backup plan.
• 37:28
  Yeah. And I don't know, I know that's
• 37:30
  kind of just like a personal decision probably, but just
• 37:33
  curious on your opinion there. Yeah, it's difficult.
• 37:36
  And again, you'll get kind of opposing viewpoints about this.
• 37:41
  But financially it's, it's very understandable if you don't have
• 37:45
  a lot of runway and you feel like, OK, especially if you were
• 37:49
  starting out from zero, which you're not, which is great.
• 37:53
  If you're definitely, if you're starting out from zero, you may
• 37:56
  want to consider that so that you could have that side gig and
• 37:59
  you just kind of hold off on taking any Medicare patients.
• 38:02
  But Rochester, Rochester's a good sized city.
• 38:06
  There's plenty of people and you don't need a ton, right?
• 38:10
  You just want 2 to 300. So, yeah, odds are, yeah, you're
• 38:15
  going to find those people that value it, right?
• 38:21
  Yeah. So 5 to 10% is a pretty good
• 38:24
  average and it it seems to really work out five to 10% of
• 38:28
  your current patients will follow you most of the time.
• 38:33
  It works out to be about that. OK, Yeah, yeah.
• 38:37
  So you may have a pretty good panel that helps starting out.
• 38:41
  But yeah, if you don't, if you don't opt out of Medicare and
• 38:44
  you are working a side gig, you could look at it as you're not
• 38:49
  going all in and you're not focusing because you're doing
• 38:52
  this other side gig. So that's taking you away from
• 38:55
  promoting your practice, from networking, from trying to grow
• 38:58
  it. So there is that.
• 39:00
  But then you also need finances. So, but one way to look at it is
• 39:06
  if you have your side gig and then you have your DPC, but as
• 39:09
  your DPC grows, you shrink this, don't just hold on to it, right?
• 39:14
  Because you, yeah, you feel like you need the whole 20 hours or
• 39:18
  whatever, start adjusting if you can.
• 39:21
  And if it gets to a point where they're like, no, you can't just
• 39:23
  work 8 hours, then then that's time to go.
• 39:26
  The thing about having or opting out of Medicare 1st and even if
• 39:32
  you don't have a lot of patience initially, that time you can
• 39:36
  really use that to network, to talk to referral sources, get
• 39:43
  out in the community trying to get new patients because no
• 39:47
  one's going to sell it better than you would, right?
• 39:49
  And if you are working your other job, that puts pressure on
• 39:54
  that time you don't have. To do now, which is actually
• 39:56
  really difficult it's my full time well my pay for service job
• 40:01
  again trying to right do this, trying to start off time that's
• 40:04
  like it's a lot yeah, so. OK, that is.
• 40:08
  Really helpful. I will say I have, I don't, I'm
• 40:13
  trying to think of how many, probably over half of my
• 40:17
  patients are Medicare. And the thing that they really
• 40:22
  care about is that they can get in, they can get an answer.
• 40:27
  They have time to talk to me. And you were asking about the
• 40:32
  value, what kind of value? I mean, that's huge to them, I
• 40:36
  mean, to anyone else too, but particularly to my Medicare
• 40:39
  patients because they grew up, one of them grew up with the
• 40:45
  town doctor, right? The old, the family Doctor Who
• 40:47
  would come to your house and, and they've seen the changes in
• 40:51
  medicine. They see how terrible it is now
• 40:54
  and they want what they had before, which is understandable.
• 40:57
  So, and plus they have just odds are if you're on Medicare, you
• 41:02
  have more medical issues and it does require time.
• 41:04
  And so that's what that's what most of them tell me that they
• 41:09
  like is that they get an answer when they call, we answer their
• 41:13
  questions, they they're able to get in and that's, that's good
• 41:18
  enough for them. Yeah, that's that's really good.
• 41:20
  Yeah. Wow.
• 41:22
  OK. All right.
• 41:24
  You convinced me. Yeah, it always get here.
• 41:28
  So yeah, try to build up your e-mail list, yeah.
• 41:31
  Hopefully by then I'll have hopefully launched my website
• 41:33
  itllbeplanteddpc.com. So that's awesome.
• 41:37
  Well, thank you for sharing. I appreciate you putting
• 41:41
  yourself out there because this is hard.
• 41:42
  Yeah, it's hard. To learn how to do this, yeah,
• 41:45
  definitely. Never done this before, thank
• 41:46
  you for having me on. This is such a absolutely.
• 41:49
  Thank you for all the. Coaching.
• 41:51
  Thanks again to my guest today, Doctor Sandra Keene, and wishing
• 41:55
  her best of luck as she opens her DPC practice in just a few
• 41:59
  months. And one last reminder about the
• 42:02
  DPC Women Connect event that's happening in February in
• 42:05
  Hickory, NC. It is an intentionally small
• 42:09
  group of women gathering to discuss DPC, create connection
• 42:15
  and community, and support for women who are just starting
• 42:19
  their direct primary care practices or have opened up in
• 42:22
  the past six months or so. If you've been thinking about
• 42:25
  DPC or looking for support from other women who are doing the
• 42:29
  same work as you, I'd love to have you in the room.
• 42:33
  Details are in the show notes below.
• 42:36
  Thanks again for listening and I will see you again on the next
• 42:38
  episode. Thank you for listening to DPC
• 42:42
  Life. If today's conversation inspired
• 42:45
  you, hit follow. Leave a review and share it with
• 42:49
  a friend who's ready for change. Remember, wherever you are in
• 42:53
  the journey, your DPC family has your back.
• 42:58
  Until next time, keep building a practice and a life that truly
• 43:03
  fits you. This show is brought to you by
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  DPC Ads in Minutes and Harmony OPS Health helping independent
• 43:11
  doctors like you. Grow and thrive.