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.

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...

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!