Some might say anyone can run their own DPC.  Some might be right.  So, I am here to play Devil's advocate on this and help you understand whether you are right for DPC.  I will start by saying that any doctor who wants to do DPC can do it but some are better doing it with the help of someone else, while some are best as their own owner/boss.

A few factors that might sway whether you want to/can be your owner/boss:

The rest of your life: if you are someone who is very involved in the rest of your life and does not want the possibility of any outside influences (i.e. patients, business troubleshooting) to take away time for day-to-day responsibilities, it may be worth considering if you should work with a partner or join an existing practice.

Boundaries: some doctors (people!) have better structure and boundaries with patients than others.  Again, I don't think you cannot do DPC at all if boundaries are not natural for you, but if you are honest with yourself and know that you often "give too much," you may benefit from being affiliated with an existing/experienced DPC doctor who can advise and guide you along the way.

Business interest: some doctors are really great at doctoring and want nothing to do with business ownership (think payroll, supply management, accounting - the list goes on!).  If that is you, consider a partner who prefers to manage those things or joining an existing practice.

If you relate to some of these hesitations, good!  I think being honest with yourself up front as you consider whether DPC is right for you is a great place to start from.  I have seen some doctors fail and I think those are ones who tend to blur their eyes to their own faults, realities, boundaries, or weaknesses.  We all have these challenges and each person is unique.  If you're not sure you are being honest or you don't know where to begin, sometimes the idea of hiring a coach can be super helpful to set your goals!

There are a number of business structures and opportunities nowadays to enter DPC without having to be your own practice. 
- Join as a partner: the most classic version is to be an existing DPC doc's partner.  The coverage sharing and business balance can be great!  But you will still have lots of say (if you structure your contracts right) and also lots of responsibility (both good and bad). 
- Join as a contracted physician or employee: this is my preferred structure for those who want the fabulous work-life balance of a DPC doctor, the relationship building classic in small practices, and none of the administrative burdens!  As a contracted physician, you can control your own overhead and keep it DPC lite!
 - Join a large group: this is becoming more and more available as the years pass.  My only hesitation is do your research.  The last thing you want to do after leaving the hospital-owned/corporate world is to end up right back in a corporate structure that removes your flexibility and independence!

ZERO.  None, nobody, nohow.  That's right, seven plus years into practice and our DPC has no staff.  And guess what - we have no need for staff and no plans to hire anyone - ever.  How do we do it?  Why do we do it?  Because it is the best way to have your practice be 100% what you want and to rely on no-one else to get or keep you there.

Costs: this is a no brainer but one of two biggest expenses in a practice is staff (the other is insurance billing and we already know direct care eliminates that).  But not having staff saves not only the cost of their payroll, but also any benefits they might expect and having to pay their social security and medicare FICA taxes.  

Reliability: I have seen far too many practices hire "the perfect MA" only to be let down a couple years later when that person leaves.  Having become dependent on their assistance (and in many cases having had them do many tasks that the doctor now has no idea how to do, makes the doc very reliant on that particular person.  When they leave (which inevitably happens almost everywhere) the doc is left empty handed, uninformed on many office procedures, and desperately searching for a replacement.  So - my advice? - rely on yourself and no one else.

Retirement Bonuses: as a self employed physician (or co-owned practice with other doctors) there are some huge 401k savings benefits.  Physician on Fire (one of my personal favorite financial independence specialists) writes about the many versions of 401k and details midway down the page how having your own business or being an independent contractor allows you to save way more than the standard into your 401k - to the tune of close to $60,000.  If you have employees, this solo 401k option is eliminated and you're back to the standard $19,500 as of 2021.  This is a huge benefit for physician owned small businesses who have no employees (although spouses are allowed to be employed as an interesting caveat!). Obviously, talk to your accountant on this one.

But I hear you still saying "How can I possibly run a practice without staff?"  Here is how we do it:
- Patients arrive and ring a bell in our waiting room; the doctor gets the patient and checks the vitals (imagine that!).
- The doctor reviews medical history directly with the patient and makes notes as he carries on.  Of course he/she does the visit, physical, procedures, etc.  
- The EMR allows the doctor easy access to schedule future visits or enter tasked reminders for next time.
- We block time to be able to spend making needed orders or referrals afterward (there is no magic science to this stuff, it is very simple!). Sure PAs come up here and there but most of the time websites like myevicore.com help make this pretty simple to do quickly and online.
- Texts and emails are responded to in between patients - our voicemail says we are busy seeing patients, so leave a message and we will get back to you - if urgent we will call quickly.  
- Our phone system texts us transcriptions so we can check easily and step out if needed (which is rare).
- We can handle many things that are clinically appropriate remotely which saves in office visit coordination and time.
- Our EMR allows e-rx, our fax is online and integrates directly to our EMR - we can be anywhere and handle all of this things!
- Patients can self schedule online with our EMR.
- We triage our very own patients (no one can decide when/where/how someone is seen but us and we do it the way we like rather than a secretary acting as middle man) - this helps the right patient be seen at the right time for the right duration which simplifies our work flow.

So, what is it you think you cannot do yourself?  
Not enough time? DPC gives ultimate flexibility so block your schedule off for admin hours or buffer before and after patients so you can handle patient and business needs.
Forgot how to do vitals or phlebotomy? Find your local DPC doc - he or she will probably give you a refresher!
Don't know how to answer the phone while seeing patients? Find an EMR or phone system with a service that allows texting the office or use a voicemail system where patients know you will see a transcription and call right back if urgent or get back to them by text/email when you have time for non urgent matters.

Believe in yourself - you are a physician - you completed medical school, residency and maybe even fellowship.  You passed medical steps and boards.  Just because the system has convinced you that you cannot doctor without medical assistants, PAs, secretaries, and billers does not mean that is true.  The only things you truly need are a doctor, a patient, a computer and a few pieces of medical equipment.  You got this!

As a business owner and physician, you need to have a major handle on your schedule.  This is more important in DirecT Care than anywhere else because patients often have access to you around the clock.  I've personally witnessed the torment physicians can undergo when trying to "be everything, to everybody, all the time."  Clearly, no one can be so this mentality always results in failure - "I'm not parenting well enough; I'm not doctoring well enough; I'm not taking care of me!"  Sound familiar?

Here are my hacks to managing a DPC schedule (without staff), a family (I have three kids and a wonderful/helpful husband!), and my own needs.

- Buffer everything!: My basic schedule includes buffers for before patients and after patients.  We use an online scheduling system that links into our EMR.  So, when a patient goes on to book they only see slots I have left open.  If someone books 1pm, I can choose to approve or deny.  Once approved, I automatically add a non-patient buffer block for the half hour before.  This eliminates the possibility of another patient being able to book something within the half hour before a visit is scheduled by someone else.  This lets me ensure that longer visits (one hour is my generic block) have the time they need without another patient booking to close.  The buffer also usually gives me extra time to finish up paperwork, call in referrals, research related topics, etc.  When I don't feel rushed, and don't put off patient-related to-do's to later, I feel like I've checked off the whole task list for that patient (note included) right then and there and can move on to the next!  

- Schedule urgent visits yourself: If it is the day before and I have any openings, I block them.  I don't want patients being able to log in today and pick a visit today for something non-urgent.  And if it is urgent, I want to discuss that with them first and be sure coming to see me is what makes the most sense.  If it's a UTI and a patient just needs a urine sample and an antibiotic - I can do that from my desk and they can save themselves another stop.  If it's a likely fracture, I can get the x-ray first.  If it's a specialty issue, I can coordinate with or refer them to where they would be best helped, Etc etc.  Granted the choice of where they go and how much you do in person can only be made by you - so I strongly suggest you be your own triage-person - and save yourself time and unnecessary headaches.

- Block time for you: Everyday my schedule starts with a two hour block.  During those hours I exercise, run errands, handle personal matters, go to the doctor for me, etc.  It took me a couple years to realize scheduling time in for my needs was just as important as for everyone else's!

- Consider a "day off": or two!  My current schedule allows three days of in-person openings for patients to book (M/W/F).  I let patients know when they join or ask that routine checkups, physicals, and non-urgent needs will schedule about 2-3 weeks out.  (As above, I always tell them to reach out to me directly for urgent needs and that while I may not always be in, I am always reachable to figure out the best steps).  The other two days of the week I am "off" - this is not something I advertise to patients but what it lets me do is have two days to either (1) do things I enjoy/spend time with family, or (2) squeeze in urgent visits if they are essential.  I usually spend 1-2 hours on these days checking faxes (online e-fax of course!), reviewing labs, answering messages, etc. but a majority of my day is my time.  When someone needs that acute visit, I can often see them tomorrow, but if not I have lots of time to do it today when necessary.  

- Take vacation: don't be afraid to take time off. As any established DPC doctor will tell you, we all deserve it at some point and patients will congratulate you for taking time for yourself!  I always email to warn a week and a day in advance that I will be out.  If I'm taking my own call, I remind them to send an email and that has an auto-response reminding them that non-urgent issues will be responded to next week.  I do have a partner who covers for me once in a while for vacation and I think having that option is worth it's weight in gold if you can coordinate it.  Many non-partnered/non-group physicians do this with a nearby DPC doc who they pay for coverage, for example.

- Accept the urgent care: in a practice with no staff, I cannot be 100% everywhere all of the time.  So there are occasions where someone needs stitches and I'm at a soccer tournament with my family, for example.  The biggest piece of advice I can share here is, let it go and realize it is OK!  Patients are reasonable and understand you have commitments outside of their every medical need.  They know you are almost always able to help them quickly and they appreciate you advising them on where to go when you can't!

It's time to say goodbye to staff double-booking you when you have explicitly asked for patient A to always have 45 minutes.  It's time for you to realize that a huge benefit to DPC is that YOU make your schedule.  Make your Direct Care practice the one you want it to be by establishing a schedule that is sustainable and ENJOYABLE for you!

If you need more specific help, join my newsletter by emailing me at [email protected] or reach out with your questions.

The journey in Direct Care is unique to you.  If you're someone who values work-life balance then you've come to the right place.  In Direct Care, you control your model.  With a simple micropractice style model, like I've owned for the last seven years with my partner, you can achieve this balance with a few boundaries and goals in mind.
When you begin your DPC it is key to understand your calculations right off the bat.  How many patients do you need?  The math is simple.  You combine the salary you desire with the hours you'd like to work. 
(1) Estimate your overhead so you can deduct that from your practice income.  
(2) Use your approximate desired salary to calculate the number of patients you need to carry.
(3) Use the patient utilization estimator to determine the number of hours you need to work in the office.
(4) Decide if you plan to have staff to fill in the non-complex patient need hours.  (I have no staff - our office has close to 1000 patients and 3 docs, so I encourage everyone to try it this way and reach out when you're feeling the need to add staff so I can help advise you on how to improve your efficiency and keep it staff-free!).  

​When I use the calculators above, a doctor at our practice requires 27 in office hours per week for 48 weeks per year to meet the demand of his or her 370 patients and come home with $250,000 in annual salary.  At 27 hours per week, that doc is in-house 3 full days or 4-5 part-time days.  I have become accustomed to a 3 day work week and prefer to use 1-2 hours on my "at-home days" to work on remote issues/administrative tasks that come up on those days.  I am able to do the administrative tasks associated with the patients I've seen in the office between visits.  (More on how I structure my day coming in future blogs!).

If you're finding it hard in your existing practice (or in your start-up using the numbers I have provided in the calculators) to make the numbers work with a work-life hours balance, I suggest considering which of the following areas could be adjusted:
- Overhead: how can you cut back ancillary expenses?  Think about what is required for excellent clinical care and access to you as a physician, and see what things are not meeting those aims and could be reduced or eliminated?  Medication inventory may be a good place to consider cutting, especially if it's overwhelming you financially and is time-intensive.
- Income: have you adjusted prices or added a sign-on fee to increase your averages?  Are you being paid well enough to sustain what you're doing?  
- Enjoyment: is it that you're taking on a certain type of patient care that isn't fulfilling or is labor-intensive and could you make any adjustments in your marketing pitch or boundaries to improve this for yourself?
- Find the middle ground: perhaps you can't make it work in under 32 hours, but you also don't need to do 40 hours.  Somewhere in there is the right balance for you - play with what adjustments you can make and find the perfect balancing act.
- Flex scheduling: use your own scheduler (I love the online scheduling features in our EMR) to block time when you start to feel over-worked, to buffer your day with time to complete admin work, and with "personal days" here and there to catch up or take time off!

The goal of Direct Care Lite is to be on a financially and personally better track during your career so that you can comfortably retire when you're eventually ready but you can comfortably enjoy your work and your life now with happiness throughout career.  If you feel stuck or way off track, consider reaching out to me for help on how to make some improvements!

Starting up a direct care practice can be very inexpensive.  With the Direct Care Lite theme in mind, I want to review how you keep costs low when marketing a brand new practice.  The great news is that YOU are your best advocate.  While I realize this concept may inspire fear in the hearts of many physicians who do not see themselves as marketing experts (never mind the fact that you're already worrying about being a business person and entrepreneur!), it is not that hard and yes YOU can do it!

If you start a practice from scratch, you have few or zero patients on day one and have to find a way to spread the word yourself.  Of course you can hire a paid marketing support person, but in my experience they help more once you've already gotten the ball rolling.  Without any patient word of mouth and without much money to fund your marketing budget, you have to strap on your boots and pound the pavement yourself.

Here are my top suggestions for self-marketing for free:
- Find all of the local online and print newspapers and email a few people you find.  Look for a content editor, someone who wrote an article you like, or any name you can find.  Send them your pitch - i.e. why you started such a unique practice, how it is new and there is nothing like it around, how this model is growing leaps and bounds and we finally have one here!  Expect to email them many times over the course of months.  Some will write something quickly and others will take time responding.  
- Link every article about you on your website - Share the link via your website on facebook, instagram and in a newsletter.  Organic publicity via shared social media links that lands people back on your website is worth its weight in gold!
- Use each article for the next one - send the link(s) to your site and the articles written about you to each new news source that you are hoping will write about you so they can see that you are newsworthy!
- Network, network, network - every person you meet should hear about what you're doing.  Tell your kid's friends' parents at soccer, tell your church group, tell the person you run into at the coffee shop.  For every person who shows any interest, get their email.  Add every email you collect to your newsletter.  If you're invited to a BNI group, say yes.  If you have the option to go to an evening marketing event for the town, say yes.  If you can attend a local chamber of commerce event, say yes!  You get the point - I promise once your snowball is rolling you won't have to do this anymore :).
- Start a newsletter - as I've mentioned above this is key.  It gives you one place to store every email you collect from networking and to put together the links of articles that you generate from local press to share with the email list.  You should also link to any blog posts you write for your practice, share photos, make it personalized about who you are and why you are doing this as you start out.
- Have a Facebook and Instagram Presence - post as often as you can remember.  Post every blog you write, every article that is published, do a "throw back thursday" and repost old articles, share photos of your day-to-day as a DPC doc, and add local events where you tag local businesses so they like and tag you back!
- Collect Google reviews - 7 years into practice we have patients all the time who join and say "your reviews are so much better than every other practice that I just had to join!"  Ask every new patient in your welcome email to review you on google and/or facebook (Google is tops because it is everyone's favorite search engine and your high review will bump you higher on searches).  If anyone gives you a compliment, thank them and ask them to post in a review (and feel free to explain it's the best way for other patients to find you!).    Use your reviews in memes on facebook/IG and in your newsletter to share the words of others recommending you.
- Blog - use your website's blog to write about what interests you in medicine, in DPC, in your world.  Make it personal and informative. Make sure to link to other articles to help with Search Engine Optimization. DPC blog examples for ideas: https://www.plumhealthdpc.com/blog,
https://www.kahnhealth.com/blog, https://www.directdoctors.org/blog.
- Recirculate - basically once you've done everything above, do it again.  Cycle through these things over and over until you've gotten to a point where you can start putting some money into facebook and google ads (and/or hire someone to help with that) and/or you have patient word of mouth taking hold.  Seven years in and one of the few expenses we still splurge on as we continue to grow our panel is a marketing expert, google adwords, and facebook advertising.  We may be full soon and end this arrangement, but for years it has paid us back.  But our first two years we did not put a dime into this and we got our own ball rolling...and you can too!

More on keeping overhead low when you startup...
More on startup cost calculations...

No two direct care practices are created equal.  If you're debating how to begin your DPC, there are many blog posts that will discuss the basics of direct care, how to open a Direct Care Lite practice, and the nuts and bolts of startup costs.  (There are also some amazing and inspiring podcasts to help you start your practice).  If you have a game plan or are deep into your own practice (which might be months or even years in), this post is meant to help you identify the best ways to "troubleshoot" the issues you find you are having day-to-day.

Our DPC is a micropractice (think no staff) with an emphasis on simplicity and low overhead.  In our case, we find the simplest solution is most often the best solution.  Regardless of your point of view in politics, many of us can agree that the U.S. government approaches solutions to many problems, especially that of our healthcare system, by adding onto a broken system, rather than starting from scratch with a newer, simpler model.  So, when you find that your direct care practice is not working the way you had hoped, it may be time to consider a simpler solution.

I advocate the "step-back and analyze" point of view.  In other words, look ahead a few days, a few weeks on your work schedule and block out a few days entirely.  (If your practice is like mine, you can spend an hour or two a day on those days handling things that arise that are urgent for patients and using the rest of your time to analyze your practice).  When you are knee-deep in daily practice and seeing a full panel of patients, your efforts to make changes are unlikely to work because the urgent needs of the patients you are seeing will take over (as it should).  Hence, I strongly advocate taking time off from seeing patients and doing a full review of your practice.

If you know of an issue with your practice that you want to fix, start there.  If you just want to do an overview of your practice and shore up some improved procedures to save time and money then consider a more general review.  When you are focusing on a single issue here are some factors to consider:
- Why is this a problem? For me or patients? And therefore, is the issue time or money related or is it simply causing unnecessary frustration?
- Time related: how can this be done using less time?
- Cost related: how can this be done with less expense?
- Frustration related: why is this bothering me or my patients and is there another way to do it?

Here are a few case studies of these concepts.

CASE 1:
I have patients calling, texting and emailing me all day during the work day and I cannot see patients and respond to others at the same time.  I want to maintain no/low staff so how do I handle this?
When you step back and look at this issue, you want to decide what is YOUR preference.  Do you prefer patients text, email or call?  Do you prefer to handle issues (that are clinically safe to do so) remotely or do you prefer to have patients come in for a visit?  Many practices evolve to allow patients to contact you via all of these methods and each patient does not have a clear view of what the physician prefers.  Managing all avenues can be overwhelming.  So, this practice should pick their preference for weekdays and for after hours.  
- In my practice, patients can send an after hours email for things that can be handled during work days and I will manage those in between patients during my work hours.
- Patients can text me during regular works hours or email via the private patient portal.  I have scheduled a buffer of 15-30 minutes that I enter myself on my scheduler (which is part of my EMR) so that after and before patient visits I have time to handle visit-related tasks and/or respond to texts and emails.  
- If a patient sends a non-urgent text after hours, I send it to myself in email form and manage it during the week.  I also send a gentle reminder for repeat offenders that email over the weekend/overnight is ideal for non urgent issues so I don't lose the text by the next work day.
- When I determined these rules help me the most, I sent this to my patients in a brief email so that they could refer back to the best ways to reach me when they weren't sure!

CASE 2: 
I can't get through all this paperwork!
First of all, big step back - what paperwork?  At our practice we've really eliminated paper about 98% of the time.  I urge you to review what paperwork you use that is wasting your time - filling out forms, signing, scanning, shredding, filing, etc. 
Examples of switches to electronic options:
- Switch your sign up forms to an online format (most patients can sign a pdf on their phones so we email a link with forms to them from our website and they email back); there are tech-savy options like DocUSign, etc but because money is money, we go the free route!
- Change your medical records request to FAX only (eliminating the address has dropped the number of paper charts we get by about 90-95%). 
- Set up an electronic fax that integrates directly into your EMR so it's a one stop shop.  If you have to file away prior charts, sign and send a form and then save it in the EMR, or complete paperwork and keep it on file - an e-fax/EMR connection does it all without any printing/scanning/filing/envelopes/stamps/you get the point!
- Scanning and shredding are the single most time consuming things I did early in practice - switch to electronic but if you must have paper, get a high speed scanner that can run a lot of pages at once and invest in a shredding service.  We have one big bin outside the office and it gets replaced twice a year - that is the best $130 per year we spend in time-savings!
- Review your paper problems and decide where you can improve tech to save yourself time and money!

I'd love to help you brainstorm and troubleshoot so shoot me an email and I will write a blog about your problem or if it's more complex, talk to me about consulting directly to help you break your problem down and make your practice work.  Remember - if the practice is not sustainable for you, then it is not going to be around to help patients, hire staff, etc so if you suffer, everyone suffers.  It's not too late to make a working change!

More on the nuts and bolts of starting or improving your Direct Care practice...

When you first start your Direct Care practice you may not know the answer to questions like "how do I want patients to reach out to me?" This means you can't teach them right off the bat because you don't know how you will want to communicate.  So to start, here's what I do.

When I meet with a new patient I explain that because of my family/work balance I am not always in the office but that I can be reached at any time.  I emphasize that after hours for an extremely urgent issue only, calling is best so I don't miss it (but when they call they will hear a voicemail letting them know I respond to urgent voicemails back quickly but otherwise will return calls during business hours).  Otherwise I tell them text or email is fine but if it's not urgent, email is the easiest way to reach me and it's their choice about using the private hipaa portal or regular/non-secure email.  I explain that even though I'm not in the office 24/7 I can help handle most things remotely and help them determine when a visit might be clinically necessary.

This sets patients up with the expectations that:
(1) I am not a 24/7 Concierge Urgent Care Service of 1.
(2) They can reach me when they need me...so anxiety about getting a hold of their doctor is unnecessary :)!
(3) Emailing me is usually best unless urgent; in which case a text or call works, depending on hour of the day and their prefernce.

I then respond to almost everything I get via text or email.  This allows me to review the incoming emails, texts and calls and see what IS urgent.  Urgent stuff gets responded to first thing when I arrive to work (after working out of course - healthy doctor, happy doctor!).  Non-urgent stuff gets handle during the day between patients when I have a window.  I almost always leave 30-60 minutes before my first patient for the urgent replies and a buffer before each visit to handle anything that pops up or wasn't handled first thing.  On my days at home, I try to allot 1-2 one hour slots to work on issues.

When I respond to questions, concerns, needs via email or text, then patients start to realize that is my preferred method of communication and most patients will follow suit in the future.  But what about those pesky patients who really want to barrage you with emails, texts, and calls everytime they see you are starting to respond?  First, anything outside of 9a-5p, does not get a response until that time on the next business day unless deemed extremely urgent.  When I do respond the next day, I first emphasize that if they have something that pops into their head after hours, it would be best to email me so I see it at work the next day to help with their concern.  This almost always helps prevent this next time!  For those who do not get it after a few reminders, I will send an email explaining my preferences on contacts for what and how.  

As you feel out your practice your preferences will solidify.  But remember, the absolute key in being burden free is being sure to model your style of communication after what you like best.  Many docs avoid texting because they find it hard to track.  Others, like me, don't love phone calls and reserve those for visits only, with a few exceptions.  Make your practice work for YOU and you can sustain it longterm for your patients!

​Read about how I keep my overhead low...

While time is money, money is also money.  Loving and living in your Direct Care practice does not have to mean spending more than you earn to keep the lights on.  It does not require a massive startup budget.  It requires some careful planning, and maybe a good spreadsheet or two!  The best advice I can give is pick and choose what you NEED and start there.  You can always add wants and maybes down the line.

Here is what you don’t need to keep your practice running smoothly:

• Staff: I know, I know, you can’t understand how but I will share the many administrative hacks on this journey.
• Fancy Office: I swear, patients want a doctor they like (get along with, solid practice of medicine, accessible) and don’t actually care what your countertops are made of!
• Pharmacy Inventory: I can hear my DPC colleagues cringing - but hear me out!  You can (if your state allows it) dispense wholesale meds at cost to patients without any inventory in stock. 
• Expensive Electronic Medical Record: Our EMR was free and is now $100/mo for each physician.  It includes fax integration, patient portal, and online scheduling.  
• Expensive Equipment: OK, OK, you need some.  But what do YOU really need to be a doctor?  Stethoscope - check, BP cuff - check, pulse ox - check.  In primary care, the list is small.  Specialists like dermatology and surgical sub-specialities might have to increase their overhead on this front; but in general picking what you NEED and starting small, allows future growth where you see fit.
• Consulting Firm: no matter what anyone tells you, YOU can do this.  Don’t pay any non-doctor to tell you how to doctor.  If you aren’t a business person (or don’t want to be - I am not and have just figured it out as I go!), consider joining an existing DPC or reaching out to DPC doctors who have lots of experience already. 

What you do need to start is simple:

• Yourself: check.
• Your practice name: finding a friend, colleague or partner to help brainstorm your mission and dream, can help identify a great name.  A logo goes a long way too and lots of websites are up and running to help you access designers who will bid on your work at low costs (or like me, ask your BFMD Hubby to make one because he’s wicked creative!).
• Your license and malpractice - check.
• Medical & Office Equipment: your average PCP needs a few items depending on what you plan to include.  As family doctors our startup list of equipment might be a bit longer than an internist (think childhood vaccines, a table with stirrups and PAP equipment, skin biopsy supplies).  But the list is not enormous and there are great hacks for finding equipment at lower costs.
• Website: many free sites allow you to start and maintain for free or very little cost.  Searching for site names that are included or cheap, is a great way to help pick your name. 
• Fax & EMR: electronic options abound in the fax & EMR worlds these days.  Unburdening yourself from handcuff Fee-For-Service (FFS) medicine is one thing.  But I urge you to unburden yourself from being in any one physical location ever.  Use technology - faxing from anywhere is a huge key to this.  I would also argue EMR is not for everyone, and outside of insurance-based billing, paper is still allowed.
• Paperwork: you need a few forms up and running for patient sign up.

What you might need:

• Physical space: while most practices start with space, there are quite a few hacks around this.  My best advice is start small and don’t commit too long. Consider subletting or a homecare/remote care option only as you build your panel and cover your expenses.
• Billing System: some practices use ACH draws from patients, others use online billers, and others have an EMR which integrates billing.  The simplest way and the cheapest way are often different.  We prefer a billing system that takes the work out of it for us, but arguments can be made for many approaches here. 
• Lawyer, Accountant, Business Licenses: starting a solo LLC is one thing; joining with a partner to form an S-Corp or purchase property under an additional LLC is another.  We swear by the advice of our lawyer and accountant and pay them like our patients pay us.  We value advice.  
• CLIA Certificate: if you will be doing any in-house labs (i.e. urine dips, strep tests, etc) you have to get a CLIA waiver.  This is simple and affordable and adds value for patients when you include these services in your practice.
• Lab Equipment: if you want to draw, run, spin, etc your own labs, just talk to a national or local lab and this expense will be covered for you on their behalf! 
• Vaccine Equipment: a much larger discussion takes place depending on which state you’re in.  For now, suffice it to say, if this is something you’re interested, it is very state dependent and checking with your local DPCs may help delineate your options.

Your practice has to be right for YOU but taking baby steps when it comes to footing the bill is the smartest way to build a simple, sustainable practice without adding new burdens to your life.

​Read more about what forms you need to start your Direct Care practice...

What would you tell the elderly mom of your disabled alcoholic patient in his 30s when she is buying him alcohol - stop enabling!  It's important that you stop enabling patients to take advantage of YOU.  No person - no doctor - can sustain being at the beck and call of anyone, never mind a panel of patients.

In Direct Care, YOU are in control of YOUR practice.  A huge benefit of the model of care is that you schedule how it works for you and you determine how you want to be contacted and seen.  Patients aren't expecting medication delivered to their door; most don't want unneeded tests once you explain the data; all they really care about is access to you.

If you offer a never-ending, never-say-no, style of practice - patients believe that is what they should expect.  If you're at your daughter's basketball game, and they're used to you dropping everything to do a home visit - then they expect you to drop everything to do a home visit.  Most of us cannot sustain such never-ending, no-boundaries care.  And we DON'T have to.  If your practice can't make it because you cannot sustain what you think you have to promise to keep your patients, then your patients will soon be out one very good doctor.  Most of us are in medicine because we are altruistic about caring for others and it's easier than most to fall into the trap of giving too much of ourselves. 

First step to rebooting the success of your over-promised practice - decide what kind of practice do YOU want to have?  If you love home visits, you have to build time for it within the work hours you prefer.  If you want to see newborns at the hospital or at home, make sure you have buffers in your schedule where you can make that happen.  Learning to say no to things that are not your priorities is one of the most important boundary-setting exercises. 

If you find yourself knee-deep in enabling, I suggest taking that step back to look at what you are doing that you LOVE and what you are doing that is sucking the energy out of you.  Make two lists and be honest with yourself!  Figure out how to remove things from the "bad" list.  If you find that you wish you were seeing more sports medicine for your own patients rather than referring that out and you realize you don't love doing IUDs - change the menu of services you offer.  If you find you can't fit in home visits for elderly patients, charge an amount fitting to homebound care so that you can see fewer patients but at the level that they and you need.

If you find yourself lost in determining how to unburden your practice, I am happy to help!  Email me at [email protected] and get on my mailing list to be updated about new blogs and calculators that can be your tools to success. 

More on troubleshooting your Direct Care practice...
More on patients reaching out all the time...