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...

​No offense, but taking an employed-physician job is easy (or at least an easy way to start).  Sign your contract, work your hours, collect your paycheck.  Just follow their rules and meet their standards.  Work with your numerous staff and focus your 7-10 minutes per patient encounter in your office on writing your note the way the insurer wants it, and coding so that you meet your RVUs.  The hard part is that this fee-for-service model handcuffs you into a way of practice and drains the love of medicine out of many of us.

You are not independent.  You are dependent in every sense of the word.  When COVID hit, did you get furloughed or have your pay cut back?  If you think you're indispensable, think again.  Your one employer can cut your pay and take your job any day he or she wants.  Independence comes from working for yourself and your patients - the way medicine was meant to be.  

Financial Independence (F.I.) - made famous by the likes of Mister Money Mustache and Physician on FIRE informed many of my decision along my Direct Care journey.  I chose independence from corporate medicine instead of signing a six-figure contract out of residency because I saw the potential independence and happiness I could achieve.

In F.I. the major motivator is savings rate - the more you save, the faster you reach your goal, and the sooner you can retire and live off of your savings.  Math makes the calculation simple and cutting back your monthly expenses makes the goal achievable.  Physician F.I. Bloggers, like Physician on Fire, XRAYVSN, and the Darwinian Doctor all have their own versions of F.I.  But, as my journey into F.I. blogs deepened alongside my journey as a Direct Care doctor, I realized the important caveat to F.I. for my husband and I as physicians - we can (and now DO) love our work. 

The best way to reignite the passion for our work has come in the form of DPC (lite).  Much like F.I., our practice model focuses on keeping overhead ("monthly expenses") at a low percentage of our revenue.  In F.I. the point is to minimize expenses --> to maximize savings --> to gain ultimate independence and freedom financially (rather than maximize income --> to continue along with exorbitant expenses).  In Direct Care (lite) the aim is to minimize expenses to gain independence and freedom professionally.

A doctor with 600 patients, at an average of $60/member/month with a 60% overhead takes home $172,800 gross income.  A doctor with 350 patients, at the same average, with a 20% overhead takes home $201,600.  If you think it's not possible to keep overhead to 20% - I have a secret to share.  I am that second doctor.  I have 350 patients and the math is accurate.  My partner and husband and I share a practice and we're at close to 1000 patients without any staff.  

When you add monthly expenses (i.e. staff/benefits and overhead) to your Direct Care practice, you lose financial flexibility and you get stuck in the Fee-For-Service Conundrum all over again - more time on more patients to cover more costs to pay yourself the same.  Time, control, and flexibility shrink away.  

​My husband, and fellow doc, wowed me with his dedication to lightweight backpacking when I met him almost 15 years ago during anatomy lab. He had recently hiked a large portion of the Appalachian trail (A.T.), a hike that runs from GA to ME, coursing over 2000 miles of terrain.  He started his hike with a 60 lb pack full of all the gear he believed he required and reduced it to 8 lbs as he realized that everything he carried with him was a burden his shoulders alone could bare.

In 2014, I started my Direct Care journey with the model of lightweight backpacking and The Ideal Medical Practice as my guiding principal.  Picture one guy hiking the A.T. carrying his 60 lb pack on his shoulders.  He is slower, more burdened and less likely to succeed than his counterpart, skipping along with an 8 lb pack.  He can switch to a side trail or move around an obstacle blocking his path with ease.  He's flexible and nimble.

Direct Care, mostly in the form of Direct Primary Care, is taking the medical world by storm.  More and more physicians burn out of being managed and manhandled by corporate-non-medical bosses and insurance-dictated standards.  Direct Care is doctors' medicine for what ails us.  A way to regain passion for medicine, connection with patients, and the satisfaction of controlling your own destiny makes this model a winning career change for many.

But, you worry about personal costs, a lack of protection, issues of loan forgiveness and a lack of support - all thanks to the golden handcuffs you've become used to wearing.  Break away with your 8 lb pack. Start your Direct Care practice without these fears.

Remove the assumption that you need to spend a lot to start your practice; that you need to hire staff; that you need to take out loans; that you need to build out your office space; and that you can't work without the support of others.  The smaller the burden of overhead and startup costs that you carry on your back, the less of a heavy leap it will take to make your first footsteps. 

The Direct Care (lite) model - aka micropractice, aka Ideal Medical Practice, aka low overhead, aka low or no staff model of care - is simple, intentionally.  The less your overhead, the quicker to pay yourself, the more pay per hour worked, and the larger the percentage of every new patient membership stays in your pocket.

The sooner you learn that patients aren't buying your expensive marketing, your fancy build out, your high-end table, or your personalized pharmacy, the sooner you realize they are paying for YOU.  Access to Direct Care docs is unprecedented and unmatched in the Fee For Service world.  You are valuable and you are the value proposition.  All you NEED is who you are - you've already invested so much time and money into becoming Dr. YOU - now you owe it to yourself to value that as your patients already do.  

Embarking upon a new path in your career is daunting.  But you're not happy and you likely haven't been happy with your career's trajectory for some time.  That's usually a big part of why you're exploring a change. Or maybe you're leaving residency soon and realizing the Fee For Service (FFS) world isn't all it's cut out to be.  

This doesn't mean you have to reinvent who you.  This means it's time to BE the doctor you've always been.  Most of us choose medicine to help others and many of us have a passion for the intellectual pursuits that are inherent in good patient care.  Starting a Direct Care practice does not mean you have to be anyone other than that Doctor who chose that path to begin with.

I hear from prospective and existing patients all the time about how they are disappointed when they join a practice to see a new physician and end up having all of their followups with midlevel providers.  They call the office to ask their doctor a medical question, and they hear back from a medical assistant.  There is an extremely high level of value inherent in YOUR degree and training.  Patients see that; corporations see that; and you NEED to see that.

Many physicians leaning toward a career change into Direct Care worry they need to reinvent themselves, stretch their comfort zones, and add new services or specialties in order to be seen as offering value.  Ultimately, most patients (the "best" ones for direct care) just want more access to you.  In any practice, most patients love their doctor - but, what they don't love is how hard it can be to reach you and to feel heard.  Allow the ACESS to YOU to be your differentiator - it's free!

​
If you're new to the concept, this post will review what it means to be a Direct Care practice.  Most accept that the Direct Care model of medical care delivery began with Garrison Bliss MD at Qliance in Washington State while others believe pioneers like Brian Forrest MD of Access Healthcare Direct receive a lot of credit too.  Regardless of the exact details of its roots, the concept has remained simple and grown exponentially.

Direct Primary Care (DPC) is the most common Direct Care practice.  Rather than billing insurance like the Fee For Service model (FFS), DPC doctors bill patients directly as a monthly membership fee.  This allows a predictable stream of income for the practice and gives doctors the opportunity to reduce the number of patients per physician, leading to much higher access for patients to their doctor.  Most practices offer cell and email access directly to the physician.  Many also offer discounts on labs, medications, and assistance in accessing more affordable imaging and specialty care.  

The major goals of DPC are affordable, transparent cost for direct access and care through a physician who is not over-burdened by patient volume and insurance-dictated administrative responsibilities.  Removing the burdens related to insurance billing (staff & related benefits, billers, data-miners, etc.) reduces the overhead costs required to run a practice.  This is what allows doctors to have fewer patients on their panels (i.e. 300-600 rather than 1000s) and therefore spend more time per patient (including in-person, remote care, researching difficult medical concerns, etc.). 

In reducing the administrative burdens faced by physicians in the FFS world, Direct Care doctors regain the control of direct care of patients, their own scheduling needs, and remove the sense that their rushing through their days checking boxes and referring patients out.  If you're intrigued by the possibility of reigniting your flame for practicing medicine and patient care, I urge you to keep exploring how I've established and run my DPC in the simplest of ways.

Keep reigniting your flame for medicine:
- Be the Doctor You've Always Wanted To Be...