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!
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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,
- 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
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.
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!
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...
If you’re considering forms, congratulations! I assume that means you’re taking the leap and now just trying to get your ducks in a row to start on-boarding new patients. The “convincing yourself and everyone around you that you’re doing the right thing phase” is over. Now you know you ARE doing the right thing to unburden YOURSELF from the system and to care better for YOUR patients.
You want to be set up with the right forms to make the on-boarding process as simple as possible for you AND patients. Many DPC practices share their forms online. Here are a few examples to look through to get your own together. I suggest reading through a few and copying and pasting the parts that make sense to you. When you have that model, go through and make sure it says what YOU want to agree with your patient about. If you feel comfortable, ask a lawyer with familiarity in the direct care world to help you review your final product.
This is between you and your patient so it needs to be tailored to what you’d like to offer in terms of services, time commitments, etc. Be careful going through it to make sure it is what you want it to be. Here are some examples: Kansas City DPC, Direct Doctors, AtlasMD. The amazingly helpful guys (aka doctors) at AtlasMD offer free services to those setting up or participating in direct care practices - one of these is legal counsel, so check them out if you have questions!
You possibly/probably need a HIPAA statement (depending on which view you accept on whether Direct Care practices qualify for HIPAA).
Medical Record Release
A couple of examples exist online of DPC records releases - i.e. AtlasMD, Direct Doctors. Copy one of these styles but remember the key in staying burden free is how do you want records to arrive? We only want faxes - why? - it keeps us burden free and paper free. We review, we send to the EMR, we are done. Paper requires scanning and shredding, both time consuming and not without costs.
Medicare Opt Out Form
If you opt out of Medicare and you see Medicare patients (remember some are disabled and younger, so ask everyone who joins!), you will need them to sign an Opt Out Agreement. The gist is, this lets them know that neither you nor they will bill medicare for your services. They can still use Medicare for everything else. Here’s a sample from AAPS.
Other forms will come up with patients as you proceed (i.e. controlled substance agreement, one-time visit agreement, and letterhead) but you will likely have time to make those as you go along. DPC Frontier has lots of form information. If you’re starting from scratch, i.e. out of residency or in a new geographic location, you will have lots of time during start up to work out these kinks. If you’re transitioning an existing practice, you may need this stuff up and running asap.
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 firstname.lastname@example.org 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...
I am a Family Physician, wife to a doc, and mother of three with a mission to convince you as a doctor that you are worth more than the system is giving you and that you are already well-equipped to make a big change without adding more burdens! My passion is helping existing or start up Direct Care practices learn to troubleshoot, streamline, and simplify.