The Thriving & Sustainable DPC Micropractice

In this episode, you’ll hear from Dr. Lauren Hedde, founder of Direct Doctors, an innovative direct primary care (DPC) practice based in East Greenwich, RI. Dr. Hedde's clinic model focuses on physician burnout, healthcare, and value-based care, offering a unique approach to patient-doctor relationships and healthcare delivery. She shares insights on her practice, emphasizing a slow and steady approach built on low overhead and patient involvement. The discussion delves into technology utilization, boundary setting, family integration, and the transition of her husband, also a physician, into the practice. Dr. Hedde's emphasis on a simplified style of DPC, known as "DPC LITE,” along with her website burdenfreemd.com, serves as a valuable resource for addressing physician burnout and promoting financial independence for physicians. With a focus on creating sustainable payment models, efficient operations, and leveraging technology, Dr. Hedde's insights offer valuable takeaways for physicians seeking camaraderie and support, especially in the realm of direct primary care.

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Transcript

0:57

Ever wondered how to build a thriving direct primary care micropractice right out of residency? Dr. Lauren Hedde did it and she's sharing her secrets in this replay. She's one of our most popular guests and for good reason, she's got a wealth of knowledge about launching and growing a successful DPC. Don't miss her tips and tools for creating a sustainable practice. And be sure to check out her full length interview update on our Patreon community where she talks about her practice. A decade after opening,

Dr. Maryal Concepcion: 1:28

Primary care is an innovative, alternative path to insurance driven health care. Typically, a patient pays their doctor a low monthly membership and in return, builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the My DPC Story podcast, where each week, You will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model. I'm your host, Marielle Conception, family physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care, direct primary care.

Dr. Lauren Hedde: 2:16

Direct primary care means to me the opportunity for physicians to be able to step outside the box, think about something that they can change in the healthcare system that has real momentum from the ground up to help themselves. Practice better and happier and live lives that are more fulfilling while helping patients in a way that's much better for them as well. With the concept of a direct primary care practice, that was also a micropractice where I am able to keep overhead low, use technology to its fullest, have no staff, and really offer that direct patient doctor relationship as the primary focus of what we do. I'm Dr. Lauren Hedy. I'm a DO, a family physician, and I started direct doctors back in 2014, and this is my DPC story.

Dr. Maryal Concepcion: 3:09

Dr. Lauren Hetty is a family physician and co founder of Direct Doctors in East Greenwich, Rhode Island. She trained in primary care at Brown and found herself motivated to start something new and better. Coming fresh out of residency, Dr. Lauren opened her practice with a goal to keep overhead low, modeling after the ideal medical practice or micropractice concept. The guiding principle in the practice has remained the same. The simplest solution is almost always the best. She and her partners have developed hacks to keep overhead low while maintaining the goals of an independent, innovative, and highly accessible practice for their patients. Dr. Hetty is releasing the blog BurdenFreeMD. com, detailing efforts to improve physician burnout, particularly in primary care, and helping fellow physicians find the courage and resources to begin their own low overhead direct care practices. Together with her husband, Dr. James Hetty and Dr. Mark Turshin, she has been practicing at Direct Doctors since 2014. Welcome to the podcast, Dr. Hetty. Thank you for having me. This is so wonderful to get a chance to speak with you because I love that you went from residency into opening Direct Doctors and now you're approaching your seventh year anniversary. That is fantastic. Fantastic. Yes,

Dr. Lauren Hedde: 4:37

it's been quite, uh, interesting journey, but, uh, definitely a success. Wonderful.

Dr. Maryal Concepcion: 4:44

Now, I want to highlight something that you had said in a previous interview. You said, I'm taking on a lot by making myself available to patients 24 7, but I feel that it's essential to provide top notch primary care. A little bit of sacrifice allows a much better relationship with the patients. And that is more satisfying than traditional treadmill practice. So I want to ask. After hearing that quote again, looking back and looking where you are now, what does this mean to you and has it changed over time?

Dr. Lauren Hedde: 5:16

I can imagine that quote is probably a good five to six years old, but in most ways I would still stand by it in the sense that I know I'm offering better care by offering better access and ultimately our practice is very simple and the concept is We offer an access that you can't get anywhere else. And we continue to do that. I think what's changed over the years is my understanding of what unlimited care means. And the fact that I'm a human being, I'm a mom, I'm a wife, I'm a daughter, and I have other responsibilities and things that I'd like to experience and fulfill in my life that I have to balance as well. So learning what. appropriate boundaries are with patients so that I can give them the access that I want to give them and that they expect while still honoring my own goals and, and purpose in life otherwise.

Dr. Maryal Concepcion: 6:05

And so many questions come to mind after hearing you say that. I want to sort of frame the rest of your story under the fact that you have how many patients in your practice and you're able to still be successful as a quote unquote micro practice?

Dr. Lauren Hedde: 6:23

Yeah. So we are somewhere around a thousand patients at this point. Um, we now have three doctors and we still have no staff and we don't have plans to add staff probably at any point.

Dr. Maryal Concepcion: 6:36

So again, if you are questioning that she just said she has no staff, that is absolutely correct. So blows my mind. Um, especially for people who are thinking about starting a direct primary care or direct care clinic, and they are working with the assumption that they have to have staff. How are you able to work without additional staff or support staff?

Dr. Lauren Hedde: 7:02

So I think. The first thing is it takes a little bit of a frame shift. So, especially if you're coming from a practice where maybe you've been, you know, used to having your own M. A. And used to having a secretarial staff used to having other administrators. Maybe you're used to working with the P. A. In the office. It's a complete frame shift. We are talking about learning to do some things that you've depended on other people to do for you. But having the time to do it and having a much smaller number of actual patient encounters throughout the day so that it's manageable for you. And that number is going to be different for every doctor for every person. And you know, my husband having just joined the practice less than a year, I've been able to kind of see him make that transition from seeing 20 to 25 patients a day for the past five years in a typical fee for service practice, being very well supported, coming to a practice, starting from scratch for himself with zero patients, and working slowly up. So one of the keys for us is that we did start out of residency, both myself and my, My partner, Dr. Tertian, um, he started a year after and joined me, but that was the plan from the beginning. We're co founders, co owners, and he and I both had zero patients when we began. So in some ways we were along that learning curve slowly with our patients. In other words, we were figuring it out as we got every new patient. How are we going to do referrals? How are we going to figure out scheduling, et cetera? We had some of the ideas figured out obviously in the beginning, but as we went along, we've learned a lot. Um, and by the time my husband joined, he comes from a little bit of a different perspective. And he could sort of point out, wow, like, you know, that this is something I would have never done, like check a blood pressure before, or, you know, check my patient in or send a referral as if some of these things are, you Like, you know, rocket science and really taking that step back and saying, well, like, I know I'm used to other people doing this for me, but this is like a thing that takes 30 seconds. Like, let's figure out how to break this down and simplify it. We don't need forms filled out. We don't need people checking in with other people. We don't need someone else talking to our patient first. We can do all that and we can get the information directly and that's going to be much better for the patient in the long run because we know them. It's not, you know, third hand, second hand, et cetera. And I'm sure that

Dr. Maryal Concepcion: 9:18

the amount of things that you need to do for. You know, any paperwork that you might need, it goes down over time because you've already done that with the patient.

Dr. Lauren Hedde: 9:27

Right. And we use technology, I will say it a million times. We use it to the fullest. We try to figure out as many ways as possible to minimize paper, to minimize having to ever have a pen around, to write something down, to sign something. We do as much as we possibly can, sort of offload it in a sense to the patient, through the use of technology, through the use of online scheduling, through the use of an online fax, because all of those things help us. To be able to do things more efficiently, but also to be able to do things from almost anywhere, if we're not in the office. And do you feel

Dr. Maryal Concepcion: 9:57

comfortable in sharing from an onboarding perspective, what tech do you use to establish a patient and see a patient as they come for future visits?

Dr. Lauren Hedde: 10:09

Yeah, so everything that we do, we always keep the cost down as well. So we have a website that's That's free that we've done ourselves from the beginning using Weebly, um, and many other options out there that do the same kind of a thing. We found, you know, the, the website that we liked the name of, and we found a theme that we liked and we've improved it over time from what it was. But on there, we have a page that has all the signup links. So it has all the paperwork that we need them to do, patient agreement, HIPAA. Um, medical record request and a link to, um, sign up for our first visit. And through that, most patients will do all of those things before they're ever coming into the office. So that simplifies it in the fact that everyone's paid before they arrive, everyone has filled out all of that information. And when we get them in the office, you know, it's a, it's a, might be a brief chat about how the practice works to remind them if they have any questions. And then it's just going straight into, tell me about yourself. Um, most of the time I don't even collect insurance information, although I know at some point I may need it for something like a prior authorization. In my mind, it might change by the time I need that. So I'd rather not waste my time and just ask for it at the time that I need it. So keeping that simple, trying to avoid paper as much as possible and then having the patient do as much as they can sort of online remotely before they show up in the office has worked well for us.

Dr. Maryal Concepcion: 11:26

When a person is filling out those forms, is it automatically uploaded into your EMR?

Dr. Lauren Hedde: 11:32

It's not. So we just have them fill them out, whether it's on their computer, on their phone, which basically almost every phone, smartphone at this point, you just take a picture and sign it. We just have them email it back to us. So we don't pay for any technology or software that does it, but we do ask the patient to just send it back. Of course, once in a blue moon, somebody, you know, is not familiar with that and can't do it and that's fine. We are capable of printing something out and signing it if we need to. Um, but for the most part, we avoid that. And then

Dr. Maryal Concepcion: 11:59

when a patient comes in for a subsequent visit, do you have them fill out any triage papers or anything prior to them coming in or do they just make an appointment and then you do everything? during the visit.

Dr. Lauren Hedde: 12:14

So they make an appointment when they want it either through our online scheduling, which is part of our electronic medical record or by texting or emailing us and saying, Hey, this is what's going on. What we often will do is even if someone's requested an appointment or their email asking for appointment, we personally triage. So in other words, if somebody says, I have a rash and I want to come in for a visit, we say, wait a minute. send me a picture of your rash. Let's see if this needs a visit. Maybe I can save you a visit or you have a UTI. You've had this before. We know what it is, or let's get a urine sample. I'll send it to the lab. I'll send in the prescription for after all of that takes me a minute and handles the patient's issues appropriately. Obviously, when something's clinically significant needs to come in the office, then we make that appointment with them or we approve the visit they've requested. Um, but that is sort of our version of triaging. We do it ourselves, which I think is better than having somebody else do it for you. Because if I know a patient is somebody who even for a small complaint needs an hour, I know I'm going to put that patient in for an hour. If I know it's somebody who I can see this person five minutes, they just want me to look at the ration person. That's something that I can do. So I think knowing your own schedule and your own preferences and your patients, you can make your own schedule better as far as how people can access you and schedule visits themselves.

Dr. Maryal Concepcion: 13:25

That's so relatable. After having patients on your panel for so long, you absolutely know your list of these people cannot have 45 minutes or less. They have to have at least 60 minute appointments because it's usually the patients who you just love talking to, or the patients who, um, tend to have multiple issues. that you're constantly addressing and who might not have as much social support, I find, in terms of my own patient panel. So I, I find that's really relatable and how empowering to be, you know, to be able to triage, but then also you don't feel like you're running behind when you finally get the patient, you know, on a telemedicine visit or in person, because you already know exactly what they're wanting to talk to you about. Yeah.

Dr. Lauren Hedde: 14:12

Exactly. Which I also like from a clinical perspective, if somebody says, listen, I have, you know, this new, um, you know, type of pain going on in my hips or something that I'm not sure what I want to, I get to consider the clinical ramifications before seeing them. I can look something up. So I kind of always know to some extent what's coming my direction in case I want to do something like that in advance. In the regular practice, you know, hearing from my husband, he can tell the secretary that you know, this patient always has to have a 45 minute visit and that patient ends up getting double booked for a 15 minute. And it's like, why do I need somebody to do that for me when I can just handle that myself and do it the right way.

Dr. Maryal Concepcion: 14:51

When you opened your doors and you had just come from residency, how fast did your practice grow and how did you handle the growth?

Dr. Lauren Hedde: 15:00

Yes, this is a very good question. And I think something that differentiates a micro practice and a straight out of residency practice from a practice where folks are either onboarding a huge panel of patients that they already had, um, or, you Um, just growing at a faster pace because of their overhead and expenses. So our choice was to have a very low overhead to not put money initially because we didn't have it towards marketing dollars to go for free sort of advertising in the form of, um, local news coverage and going out to networking events because we had time. And because we didn't have a panel following us, we grew slowly with our patients. So. Our, my first year when I was on my own before Dr. Turchin had joined me, um, I probably was somewhere at 100 to 125, like maybe 10 patients a month at that point. It's hard to remember exactly, but somewhere around there. And we had gone to a DBC conference and heard many people talking about how they got 30 patients a month, 30 patients a month. We always have this, you're always going to get 30 patients a month. We're still barely at 30 patients a month, but when you look at the math, which is very simple in direct primary care, here's your average patient, Fee that's coming in. Here's the number of patients you have. Therefore, that's your income. What's your overhead. You take that out. Our overhead is around 20%. So when you take that out, we do not need, we never needed to grow that quickly. And we didn't need to have the 600 type patient numbers per doctor because our overhead doesn't require that we could. And I do think we could, we could handle it, but we don't necessarily choose to do that because we choose a little bit more of a balanced lifestyle. Um, But ultimately, I think making the choice to have a very simple style of micro practice was a choice to grow slower than rather than putting a lot of money into build outs and marketing in the beginning. We didn't want to take a loan. We didn't want to owe anybody. We wanted to keep it simple. And because of that, we are where we are now without owing anybody anything for what we do.

Dr. Maryal Concepcion: 17:41

That's beautiful. And I want to highlight Your blog, because you have a website, burden free md dot com. Can you tell the listeners who might not be familiar with your website, what it is and what you focus on there?

Dr. Lauren Hedde: 17:55

So right now, the website is kind of my latest baby. Now that my youngest is three and a half. Of course, I needed another project. Um, I am extremely passionate about the idea that physicians are burning out left and right, either leaving practice, leaving clinical practice, retiring early, choosing not to go into primary care in the beginning. So, including med students, seeing how terrible it can be and how poor the pay can be in primary care for all the work that people are doing. And, The answer to that is coming down from, you know, corporate America and insurance companies to add a scribe so you can see more people and have somebody do your notes for you, or to add in some yoga and meditation so that you can improve your mindset and outlook on this terrible job that you have. And to me, it's, it's rude and it's infuriating and it's. It's taking away the power of being a physician. We earn this, we pay a lot of money, most of us, to get here. We spend a lot of years in school and then training. And to be told that we have to work a certain way because that's the way that the insurance company and the corporations like it the best is unacceptable to me. And I found a different way to do it. And my partner's found a different way to do it. And my husband's found a different way to do it. And we are happy. And our patients are absolutely thrilled. So my website, my blog that I'm working on is about helping people understand that this is something doable for any physician that you don't have to have experience in business. You don't have to think of yourself as an entrepreneur. You don't have to have a lot of money saved up in the bank that you have the skills already as a physician and all the training you've been through. to open a simple micro practice style direct primary care, which I kind of coined the term of DPC light after the concept of lightweight backpacking, which is something that my husband's very fond of and taught me about on his journey in the Appalachian trail and take that concept to mean that we can all do this and it's simple. And here's the steps. And I'm kind of helping people laying out. Here's how you can do it. I found over the years. A lot of people are like, wow, there's no way I could do this without staff. There's no way I could have done it without alone. And I'm like, yeah, no, you could have. You definitely can't. I mean, I'm sure there's some people who that's not the right style and I completely appreciate that. But many, many physicians can take this step if they realize how simple it is. And so rather than me talking about it to hundreds of different people, I figured I might as well write it down in one place so that people who are interested in this concept and this style can refer to this blog to, to figure out how to do it.

Dr. Maryal Concepcion: 20:26

One of the things I find really unique is that you have a tab specifically for calculators. So can you share about what that is?

Dr. Lauren Hedde: 20:35

So this is still in the works, but my idea is to be able to have. So one of my thing side things that I'm passionate about is financial independence. F I like the fire movement, physician on fire. Um, there's x ray vision. There's so many different doctors who are in this movement. Now, Mr. Money mustache kind of started it all in general and through kind of reading and learning about F I, um, I kind of started to realize that like this in a way applies to the type of practice that we're doing where. The concept is lower your overhead. So the concept of an FI is lower your expenses. It's not necessarily go and make a ton more money to spend a lot more money because you just find yourself on the same treadmill, this like hamster wheel, which is what we're kind of gotten ourselves into as physicians in a lot of ways. So in order to kind of remedy that, it's like, let's keep it simple. Let's bring down the overhead and let's make this something that is, um, you know, much more doable and, um, gives you professional independence. What,

Dr. Maryal Concepcion: 21:34

what do you say to somebody who argues, but I have to do some kind of moonlighting or I have to do some kind of side gig to be able to pay off my loans or to be able to pay off my, my overhead startup fees.

Dr. Lauren Hedde: 21:49

So everyone's situation is obviously going to be unique. And I respect that. I believe that for most physicians, either you have loans or you don't, many of us do. And as far as the loans go. There's a lot of good data and information out there about how to pick the best plan for you. But if you're in a government repayment plan, as we've seen during COVID, there's benefits. We haven't had to pay our loans for a year, basically. But the income based repayment is great for direct primary care, because what it means is When you're starting your practice and you're not making much money or you're making a lot less than you were and you can't afford the big loan payment you used to pay, the income based repayment will adjust so that you can pay it. So for the most part, I feel like physicians can work on that one if they have the loans. Um, there's always the argument about public loan service forgiveness, which, um, you do have to forfeit if you go into direct primary care right away. And that's, you know, a big topic I'd love to see the AFP and, and other primary care organizations take up, um, with the government because I don't think it. It's necessarily fair that a specialist who makes five times as much as me gets their loans forgiven because they work for a hospital. But side note on that one. Um, but anyway, the income based repayment is fine and we can totally make that work. When it comes to your own income, again, obviously this is something that everyone's going to have to figure out themselves. But my point is you don't need tens of thousands of dollars. Most people can probably start a DVC micro practice with 10, 000 give or take maybe a little more depending on what you want to do. Maybe a little less. If you want to start with no physical office space, there are hacks to do it. There are ways to do it. There's, you know, I've had people who have taken out a 0 percent credit card and paid it off within the next 15 months before it started charging interest. So there's always ways to do it in the concept of a micro practice and a simple style means that you don't need a ton of money and you can start paying yourself. Quickly when your overhead is low.

Dr. Maryal Concepcion: 23:40

To highlight a, another way of thinking about doing a micro practice, especially now with the pandemic, um, even something as simple as Google suite and a communications platform. Literally that's less than probably what, like 50 a month. To, to start out, even if you don't have an EMR, but a strategy somebody had shared with me was consider that and consider getting an EMR when you have 50 patients or more, there are

Dr. Lauren Hedde: 24:10

so many ways. Like, and that's part of what I'm thinking about calculator wise. Like here's the absolute basics. Like you have to have a phone number. You probably have to have some kind of fax number. Beyond that, you need a license and malpractice, and you need your stethoscope, which you probably already have, and a couple pieces of simple equipment you probably already have. And like, literally, that's all you need to be a doctor. You can go do home visits to start out. You can drive around in your car, and you can make, you know, take care of newborns if you're a family physician. Like, there's so many ways that you can get going. And if you calculate, What are the expenses of those essentials to be able to start? Okay. Maybe that's 2, 000, 3, 000. When am I going to make 3, 000? Well, I need, you know, X number of patients in order to cover that. Because the great thing about the membership is if you bring on 500 a patient's month one. And you bring 500 to patients month two, by month two, that means you brought in a thousand dollars. And by month three, you're at 1500. So at that pace, you're covering the overhead. That's essential by six months. And then you add on whatever the next thing is, or you start to pay yourself a little bit. And then you see what's really essential. I do not advocate for taking out a loan and spending a million dollars on building out, you know, office space and making it really nice and fancy, because when it comes down to it, people value access to their doctor. That's what's missing in the traditional fee for service practice. It is not a fancy office that's missing or a nice nurse that's helping you, you know, draw blood. It's the access to the physician.

Dr. Maryal Concepcion: 25:33

And I think that's important to highlight also because for physicians who might be in a more rural setting where unlike other DPCs where the value is brought in by, you know, cheaper lab costs or cheaper imaging. The value to a patient in some someplace like a rural environment might be just, Oh my gosh, I can actually speak with my doctor. And you're right in terms of it, it is not necessarily, you know, written in stone that you have to have a brick and mortar to be able to give those patients that value by access to you as a physician.

Dr. Lauren Hedde: 26:08

Exactly. I mean, I think the idea of starting out with home visits is not something most would be upset about. Now, also since COVID, telemedicine is so huge that you could do some of your stuff on, you know, Zoom videos and then the people that really need an in person visit, you go do it at home and you could do that for, you could do that for a year or two probably. I mean, you make, maybe you could do that forever if you really wanted to. Um, the flexibility of just the ways that patients can access you nowadays are so huge and just allow you to have such flexibility in how you want to practice.

Dr. Maryal Concepcion: 26:38

I want to go back to when you mentioned Mr. Money Mustache and Physician on Fire. Are there any particular podcasts from those resources or other podcasts that stick out in your mind as podcasts that you must listen to?

Dr. Lauren Hedde: 26:49

Um, well, one thing I will say that the first thing that pops in my mind is I listened to the podcast you did with Garrison Bliss, and I feel like anyone who's interested in direct partner care, even if, I mean, almost seven years in. I, you know, you have to hear somebody like that who did this, you know, from the start and had these brilliant ideas that we're all now piggybacking off of. So I think that that was a really interesting podcast to listen to. Um, for some of the financial independence stuff, I think it's super interesting just for physicians, but for like everybody in general. Um, and going to Mr. Money Mustache's website is the best thing to do and look at his, like, he's got a link to like the top ones are like the major, the most important, like, Read those. And if you, if you're into it, you'll know it like within a few of those that, that this is like a really interesting concept that you can apply to so many different aspects of your life, business, et cetera. Physician on fire is the one I think who does a great blog about the four different physicians, which I think is a really interesting one. And Good to look at like, who am I and who do I want to be? And again, that kind of ties back and I'd love to do a blog and like, sort of, um, You know, homage to that blog about the four different types of direct primary care or, or not even right here, but the four different types of physicians within this world of TPC versus fee for service and sort of, are you, you know, working really hard to see all these different patients and always feeling like you're behind and you're working at home and just kind of keeping up on the treadmill versus. You know, like the balance that you can have and sort of what kind of physician you want to be. And I can just envision

Dr. Maryal Concepcion: 28:25

your development of that on your blog. As somebody who eats, uh, at a, at a voracious pace, all of this information about business and finance and how it can relate to healthcare and you as a physician in healthcare, it would be really interesting to go to Physician on Fire. Read that information. And then, as you develop your take to then be able to use that information, relate to what you're saying so that a physician can even be more prepared to share that information with other people who are interested in direct primary care as the movement continues to grow. Absolutely.

Dr. Lauren Hedde: 29:01

And I think, you know, that highlights the fact that my point of view is that This isn't just direct primary care. It's direct care. And ultimately there are specialists, not, you know, not every specialty, not orthopedic surgery, probably like people who need to be in the hospital and need to be in a hospital. And I get that. Um, but there's quite a few specialties that work more on a primary care type of pattern that I think could really explode in this world of direct care too.

Dr. Maryal Concepcion: 29:29

What is your opinion on new tech that might Come out and potentially could be helpful for your practice

Dr. Lauren Hedde: 29:36

over time. And this is where my partner and my husband and I, like, it's a good balance. Cause everyone kind of comes out things a little bit differently. Um, that we'll look into something and be like, okay, like, is this worth trying to integrate? Like, is this going to either save us time, who's getting this money, you know, make things easier for our patients to get our patients. It doesn't like apply. And all those levels that, or we're doing something that maybe takes, you know, 30 extra seconds and we feel like, you know, that's not going to change it. Then we often say we're good where we are, like, let's try to keep the focus on simple as possible, but we're always kind of looking at and reevaluating. Is there a way to do this better, et cetera, as we go along? And we've definitely evolved. Like, we used to do more printing things out more paper signing. Like, we did a lot of that more in the beginning than we do now. Yeah.

Dr. Maryal Concepcion: 30:24

I want to highlight the fact that you are in practice with your husband.

Dr. Lauren Hedde: 30:29

Yes. So the funny part about it is my husband and Dr. Trishan look a lot alike. So even before my husband joined the practice, people thought Dr. Trishan was my husband. And now that my husband's there, people come to see him and think Dr. Trishan is him. So there's a lot of that hilarity going on constantly. But um, It, it's been great having a partner for me from the beginning was key in allowing me to have two babies while I was in my direct primary care practice and be able to take the time off that I wanted to to be completely away from practice. Um, and we knew when we were making this decision many years ago, you know, sitting on the OB floor in the middle of the night in residency, um, that that was going to be an important piece to have that flexibility of having a who was not my husband to start off with. So that when I wanted to be out, take vacation, et cetera, there was a way to do that. Um, so that sort of idea hatched from the beginning and has worked really well. And, you know, we've been very lucky in that Dr. Trishan and I as partners have worked out wonderfully. Um, the idea was always that someday my husband would join and ultimately it took him a little bit longer than we probably thought it would have after five years, because the job he was in was, was good. It was fine. He paid well, you know, like there weren't enough reasons that he was, he wasn't dying to leave. But ultimately we got to the point where we felt like the balance for our work family life was not as good as it should be or could be. And, you know, his, he was driving 45 minutes both ways. And he was getting to the point of starting to feel a little bit overwhelmed with work. So many patients and so being responsible for so many lives, so to speak, um, worrying he was going to miss something worrying. He was just, you know, going too fast and skipping over things and all that. And I said, you know what? Like, I think we're ready for you. I'm at the point where I think I have enough patients. Dr. Trish and has stopped taking patients already for a while. Um, so like, let's do this. So, you know, he's always wanted to do it, but the hesitation is hard to make that. Yeah. Make that transition and I kind of like liking it. So you just got to rip off the band aid because there's not going to be necessarily a point where it's like, you know, either I hate my job so much or I'm just dying to. So sometimes you just have to rip it and go for it. And that's what he did. And of course we had no idea it was going to happen in the middle of COVID when he gave his notice the October, the prior year that when he was leaving in May, it was like, the heat of COVID and we had no idea how that would affect everything. But, um, it worked out just fine. As we now know, GPC practices did great during COVID. Um, and ours was no exception. Working with him now, I always tell people, I mean, we met in medical school, we did residency together. We love to work together. So we're extremely happy to be at the same practice. We've always wanted to be, but we're physicians. So we work independently. So, you know, I'm not telling him what to do and he's not telling me what to do. So I think that's great. That's an important part of it too. But the balance that we have now in our work and our life and being able to have days off together frequently and not have him be gone in the morning when the kids have to go to school, all of those things are just, you know, immeasurably wonderful for us. And, and thing we've really felt like we've hit like our stride as far as the balance for work and family.

Dr. Maryal Concepcion: 33:33

That's awesome. And when you said, yeah, I think, you know, it would be, it would be great if you could come now. At what point did you and Dr. Trishan decide, yeah, I think we're okay with the number of patients that we have on our panel that we can bring on your husband in this case.

Dr. Lauren Hedde: 33:48

For us, we, uh, as our family obviously wanted me to be making enough money to cover our expenses so that when he made that transition, um, you know, there was no pressure on him. It was just Do this at the pace that works for you. Um, and I think, you know, in general, both Dr. Tertian and myself and now my husband, I've always kind of had the goal that we felt like we want to make a salary that's at least equivalent to what other doctors are doing in the area. And, you know, ideally a little bit more. Um, and Rhode Island is a very low paying state. So the bar was low and we definitely are making more than our colleagues at this point. Um, it, at a level that we feel like is. Fair and reimbursing us to the point that we kind of feel like our value is so I think that that was part of it, like, kind of adjusting that. And ultimately, we raised our prices a little bit over time as we've sort of felt like the value wasn't quite enough for certain situations. Um, so my husband has benefited from that in the sense that. His average is higher than ours. So he ultimately, you know, may not choose to take as many patients based on that. But then again, you know, the balance of Dr. Tertian has like 425, 450, something like that. I have like 350. Um, I chose, you know, to end a little bit early because I kind of hoped my husband and I would be at a similar number because I think that's better than me having like 500 and him having 200. I think I'd rather we just be even. So a lot of those factors go into what is your number, but I think the calculator again, You go back to that, you say, what do I want to make? How much do I want to work? How many patients do I think I can manage in that? Um, and you figure out where your balance is. Do you guys experience churn often in your practice? Oh, yes, absolutely. I think everybody will tell you that's part of direct primary care. It's part of any practice, any, you know, primary care practice. Um, I'm not sure it's any more in direct primary care than it does in other practices, but we certainly, um, you know, have patients passing away because we do a lot of homebound elderly care. So that's something that does affect us. We have people moving, we have people coming and going, we have people leaving. Sometimes we don't know why, but for the most part, you know, it's sort of the people that are moving and the people that are passing away that make that. that change. So, um, you know, I, I've sort of managed that by opening a wait list. And then when I do have a little bit of flexibility and I feel like I can take another patient or two, I put that out to the wait list and, you know, see kind of who's ready at that moment.

Dr. Maryal Concepcion: 36:08

And how do you manage your wait list? Is it built into your EMR or do you have it separate? Um, I actually just use a Google form that's on the website. I want to bring in another example that you had written about in the, in the past, because you had a patient meeting and frankly demanding your attention for a non life threatening, non urgent issue. And the patient was contacting you on the same day you had your daughter's first soccer game. So I want to talk about boundaries because especially being a mom, a wife, a mother, a doctor, a micro practitioner who is successful and has more than one child. How do you go about establishing and solidifying boundaries for your life and your practice?

Dr. Lauren Hedde: 36:58

So I think it's been a learning process for sure over the years as many of us in our primary care would probably say when you first start out, you want to please everybody. Um, and I think that's a young doctor thing in general. You, you want everybody to like you and feel like you're doing a good job and you're doing everything again. I think early on, um, my pitch about my practice may have led this particular patient and maybe others to think that I was sort of on call in the sense that any, Any moment of any day at any point for any reason, I could show up at their house for a visit. And, um, I may have meant that in the beginning and I realized over time that that was not something that was sustainable for me. And that was not the practice that I wanted. And I constantly advise people when I talk about this, that you need to make this the practice you want, because in the long run, whatever you're consistent with is what your practice is going to be. And if you're consistently giving drop of the hat home visits, because you're passionate about doing that, and you love that. Awesome. Like make that your practice. If that is not what you want in your life, then don't promise that and don't do that and make those boundaries. And there's learning blocks along the way and assembling blocks. And you know, that was a difficult situation for me where I basically, um, you know, had moments where I had to ask certain patients to not necessarily to leave the practice, but I had to encourage them that this is not the kind of, this is not what I can offer. If you want something where any, any moment, any time of the day, anywhere, any reason. That's called an urgent care. I'm not able to do that. I'm a human being. So once I realized that about myself, I could explain that to patients. And so now when patients join the practice, I explain that to them. I am accessible to you in an unlimited capacity. If you need to text, email, or reach me, we will then decide based on clinical necessity. Whether you need a visit, I can usually see you within a day or two, if absolutely necessary, and I can't, my partner can fill in for me. But typically, we can handle a lot of things remotely, and anything that's really that emergent, you may need the emergency room. So I just phrase it differently, and I've never had a problem since. And if a patient reaches out to me after hours. And it's not urgent. I don't respond till the next morning. Um, or I asked them, you know, please email me if it's something not urgent. Like I sort of help train patients over time. What is the appropriate way to have the right boundaries with me?

Dr. Maryal Concepcion: 39:13

So earlier you had mentioned how, when you were starting out and you had more time to reach out to avenues like the media, um, and get publicity and get free marketing that way. How, I want to ask, how did you go about doing that?

Dr. Lauren Hedde: 39:30

Yeah. So I think Absolutely. In the beginning, figuring out a marketing strategy is important and there's lots of different avenues. You can go with us wanting to keep our overhead as low as possible and not having much income in the beginning. We decided to go free whenever possible. So, the way that I did that was, I went through the local town newspapers, the local state newspaper, the online newspapers in the area, and I emailed. Whoever I could find editors, a writer of an article that I read and I sent them all an email explaining, this is what we're doing. It's new, exciting. It's different. We're the only ones doing it so far in this area. And wouldn't you like to talk more about it? And of course, many people never got back to me, but enough people did that. We ended up on the cover of the Providence Journal, which was a big deal. We ended up with a couple of news stories on TV and we ended up with a handful of, you know, local newspaper stories. And from each of those, we got, you know, a couple, five, maybe 10, 20 from the Providence Journal because it's a bigger reach. Um, but we didn't pay for any of it. So as we were getting going and starting out, I would just keep reaching out. And if I hadn't heard from somebody, you know, yet, I would reach back out to them. And oftentimes they would say, Oh, yeah, sorry, I didn't get back to you. We have time to run the story now. So let's do this. Um, and between that and going myself. To local marketing, uh, local networking groups, like a B. N. I. S. Um, whatever I was invited to, I would go and do my one minute elevator pitch, which I therefore practice a lot and got better and better at over time. Um, I started to get that ball rolling as far as patients coming in. It's a slow ball at first when you're going from zero. But as you start to do that, you hit some sort of critical number, which I feel like is around 75 to 100 patients where patients start referring patients. And that really gets the ball rolling. And ultimately, from that point, putting all that stuff, all the local press that we got onto social media, pushing that all out there, We eventually got to the point where the ball was really rolling now, a couple of years and we did eventually hire somebody to help us do the social media marketing to help us to get on top of doing blogs and videos and all of the things that are up on our website and on our Facebook page at this point, um, to really take us to the next level. But we waited until we had the income to support that

Dr. Maryal Concepcion: 41:48

as your practice grew, as people were hearing you and seeing you and reading about you in the media, if they would contact your practice, Would they get a voicemail that you would call them back or would they get an, if an email back if they reached you through email, how would that work on the patients from the patient's perspective?

Dr. Lauren Hedde: 42:06

Yeah. So there's some information on the website and then from there, people would either email or call. And. Um, you know, at over time, I developed sort of an email that I can copy and paste that is here's the spiel on the practice copy paste. Everybody kind of gets the same thing. And I tweak it a little bit. If there's a question, we still and always have let our voicemail go to voicemail and on our voicemail. We say something very particular about the fact that because of the way our practice works, we're not able to answer the phone. Please leave us a message. We promise if it's urgent, we'll get back to you. And if you're a new patient interested in joining, please check out the website and give the address. That has really helped us as far as workflow because we're not trying to answer the phone while we're seeing patients. We're letting people know that if it's something urgent, we will see it, hear it, get back to you. And if it's something where you're interested in the practice, go online, read about it. Maybe it's for you. You sign up for a visit and that kind of skips a little bit of a step forward for us. Um, and over time, those workflows have really worked well for us and patients seem to be fine with it. Occasionally someone will leave a voicemail and want to call back. And that's fine. We'll do it when we have the time to do it. You know, not a problem.

Dr. Maryal Concepcion: 43:09

Being that you are approaching your seventh year anniversary, I'm sure multiple people have reached out to you in terms of, you know, your story. How have you done it? How have you been successful up to this point? And how do you go into the future? What are some of the most Common questions that you hear that you haven't already covered from people interested in your model of practice.

Dr. Lauren Hedde: 43:32

Everyone wants to know how do we do it with no staff? How do we keep our overhead so low? And I've kind of answered a lot of those questions as far as the things we do ourselves. We try to offload that onto patients whenever it makes sense and using technology to its fullest. Beyond that, I'm trying to think of, like, what other kinds of questions I often get. I would say it usually the next step is really more of the nuts and bolts of how do you run this kind of a practice, which can get into some nitty gritty details and everybody likes to do it differently. Um, but when you're talking about your workflow, people want to know, like, Do you have a waiting room? Like what happens in the waiting room? You know, and pre COVID people would walk in and ring a bell. So that's why we don't have a receptionist because a bell does the same job. Nowadays, COVID has made it even simpler and patients text us when they're there and then we let them in. And it really things, these little like quick workflow things start to make you realize, like, How easy it is to just keep it simple and how unnecessary it is to add layers to something that can be done so simply and our patients absolutely appreciate the fact that it's just easy and so many patients walk in the door for the first time and go, I thought this was too good to be true. But like, here you guys are, you're doing it. And we're like, yeah, we are like, you know, it's working. It's great. Um, but I think a lot of those little questions about how do you do this? How do you do that? Like the little details and the nitty gritty is kind of the next level of what we get a lot of, um, and can be really tailored to the individual, but there's a lot of general themes to it.

Dr. Maryal Concepcion: 45:00

Going along with the direct care light idea. I want to shoot some rapid fire comparisons at you to see what your take on these comparisons are. So disposable versus autoplay.

Dr. Lauren Hedde: 45:13

Autoclave. We don't do enough procedures that it isn't easy to autoclave like once a month. Like, we have a couple of the things that we need. We have one set as far as like IUD type of equipment because we just don't do enough that we would need more than that. And then we've researched for a long time an autoclave that was about a thousand twelve hundred dollars and we Sort of compared that to the idea of having to buy things and how much that would add up to be. And ultimately the autoclave made the most sense for us paper versus no paper. So obviously no paper, very biased on this respect. One, I care about the environment. That's a big driver, but two paper is. A creator of clutter and an issue to deal with. So we cringe when we get a big stack of paper records from another office, which still happens once in a while, but we put on our records request only our facts for the last few years. And that has really cut down and the number of paper charts that we receive. Um, but when you have a stack of paper, you have to do something with the paper. So you have to. Scan the paper and you have to shred it or you have to file it and all of those things. If you think about that overhead, overhead, overhead, space, space, space, the more you can limit that stuff, the more you have it all in this technological space, the less work time money goes into it. And those are always the things we're looking at

Dr. Maryal Concepcion: 46:41

in house pharmacy versus not

Dr. Lauren Hedde: 46:44

having an in house pharmacy. We do not have an in house pharmacy. We do offer wholesale medication to our patients because we are able to do that in Rhode Island, but we do not stock medications. So when we looked into the concept of having a pharmacy, we realized we would need labels, label printer, inventory that you have to pay for, inventory that you have to keep track of, pill counters, I don't even know what else you need because we don't do it. What we do is, when a patient needs something, let's say they're not sure if they can get their amitriptyline cheaper through us. We look up the amitriptyline at the dose that they're on and say, look, we can get you 90, we can get you 100, we can get you 500 of your 25 milligram amitriptyline for 2 or for 5. Which would you like? Or, okay, you can get it at the pharmacy cheaper, great, you know, keep doing that. If they want us to order it for them, we wait until we've added up the number that we need in order to get free shipping, so it might be a couple days. We get it shipped, we hand the bottle that we get, put a little handwritten label on it to the patient, or they pick it up. So we've eliminated all the cost of inventory and bottling and labeling and all of those things by just ordering it when people need it. And for us, that's been a huge money saver, and it's been a great way to offer a benefit without it costing anything to us. Lab discounts or

Dr. Maryal Concepcion: 48:02

not offering

Dr. Lauren Hedde: 48:03

lab discounts. So this decision was made for us because in Rhode Island, we cannot do client billing for labs, so we don't have the ability to offer great prices on labs directly through us. If we could, I think that would be something that we would have to really consider because when you offer it, it's not a cost to you, right? So the lab gives you everything that you need. And we still have all those supplies. We still draw for some patients when they want cash pricing, which is somewhat better than if they go to the lab, although that's kind of gotten worse and worse over the years, unfortunately. But ultimately the concept that you have to offer labs, that you have to offer, uh, imaging, or you have to offer all these add ins. In order to get patients to see the value in you and your practice, I argue against. In our practice, patients join for our value of being accessible, being the doctor that is directly available to them. It's not the added services and we've been successful just doing it that way.

Dr. Maryal Concepcion: 48:58

And the same question in relation to imaging. Imaging discounts or no imaging discounts

Dr. Lauren Hedde: 49:05

over time. We found local imaging places and talked with them to get what their cash prices are so that we can offer that information to our patients who want to be able to do that, whether they're uninsured or have a health show or have a high deductible and want to go that route because you're never going to meet their deductible. Um, and we found that at least being knowledgeable in that is much different than most doctors in the practices down the road. And that's enough that when people do need that, they can get it from us. And we haven't found the need to go beyond that.

Dr. Maryal Concepcion: 49:34

You've already said that you do home visits, but why home visits versus not doing home visits?

Dr. Lauren Hedde: 49:40

So we have found that there is a niche within our state of patients who are just unable to access care without home visits. The ability to leave their home, whether they're elderly, which is who they are for the most part, or younger and disabled, or another service we've offered is, um, homebound visits for newborns in the first month of life. We feel like we're targeting a population that their needs are not being met otherwise. And we do charge more for the, um, full homebound care that we offer to our elderly patients. But the ability to give that level of care to them when nobody else is offering anything near it, and to be able to be a part of often end of life care as a mix in that, um, is really one of the most rewarding things we do. And I think it really adds a nice balance to our practice. Business plan or no business plan. We didn't really have a business plan in the formal sense. None of us are like business school trained. And ultimately I think I did end up writing one later as sort of an exercise. Um, and because early on I did this pitch contest where I think I might've had to submit one, um, But we did not start with a business plan. We absolutely started with a plan. So we, especially my husband and I, obviously, we're married and, you know, we sit up and talk every night, went through a million different possibilities of how to do this. And ultimately, I think the key factor was talking with other people. Dr. Chershen talking with my husband and I, and all coming to the point of like, what's the goal for us? And the biggest goal was we want to be paid in a sustainable way. We want to enjoy our practice and we want to have time for our family. And because all of our goals aligned, we then were able to say, okay, this is what we want. Here's the practice options. How do we work the practice options and the financials and the, uh, actual setup to attain that goal. And, you know, along the way, it maybe wasn't, um, as direct of a path. Like you learn so many things as you're, once you're in it, that you want to change that you didn't realize you would have wanted this way or that way. Um, but ultimately, if you keep your goal in mind and you keep your methods You can get there.

Dr. Maryal Concepcion: 51:49

Now. I want to shift to folks who have started already or who have been in practice for a while. What advice or what words of motivation can you give to somebody if they're having, if they're hitting a rut, like if they are not having, you know, 10 to 30 patients during their practice in a month, how do you get through those tough times, especially early? when you might be in a practice where there's no staff, no other fellow physicians with you?

Dr. Lauren Hedde: 52:18

So I think the first year to two years in any direct primary care practice is uncertain times. Um, I hope now people who are starting out have more confidence that it's going to work ultimately than maybe I did when I first started and didn't know very many people who had ever tried it. Um, I think the model has now been proven, but everyone Does their direct primary care or their direct care practice differently and there are certain flaws that are Uh more detrimental to a practice than others obviously one of my my big concerns is when people hire a bunch of staff or Put a bunch of money down in the form of a loan or a lot of money out of pocket Um to get started because I think that starts you off in a unnecessary hole So I find that Once you're rolling in the practice and you don't feel like you're moving in the direction you want to be moving, don't be afraid to stop and take a look at what you're doing. I know it can be hard to feel like I've already put this money in. I've already hired these people who are depending on me, but when it comes down to it, if you cannot sustain the practice that you're building, all the staff will be gone. All the patients will be out a doctor and you'll be searching for, you know, whatever the next thing is for you. And obviously if that's what you got to do, that's what you got to do. And I respect that, but taking the step back and saying me continuing to practice in a way that is fulfilling and sustainable to me, where I'm paying myself, what I deserve should be paid. is important to allow all these other things to happen. They're all dependent on me. And if I can't sustain a practice, then everyone hurts. So I think that fear of feeling like you're not doing it right and you need to change is too much. I just got to get out of this. I would encourage people to really take that step back and reach out for help. Like talk to people who have done it and have gone through probably many of the concerns and questions and jumps that you're going through, um, and, and get advice on what you can do and have someone objectively look at your practice and what might be able to be tweaked to improve it.

Dr. Maryal Concepcion: 54:13

I love that you say that because it just makes me think of a recent episode that I had listened to on the biz chicks podcast, that's CHI X. If anyone is wanting to listen, they were talking about, or the host was talking about the 80 20 rule and how in all of the things that a person can put into a business, only about 20 percent of what you're actually doing is going to make an impact. And to reevaluate that. 20%, what is actually working for you and taking that 20 percent and, and really running with it. So I think that the idea of speaking with other people, especially as important to, you know, potentially focus in and try to figure out what that 20 percent is for a practice, but also just to have that comradery and that platform to, you know, to, to be able to share with other people, your frustrations and, you know, most of the time, you know, Especially just reading things on the Facebook group, somebody else has gone through that experience as well. Exactly.

Dr. Lauren Hedde: 55:14

I think the Facebook groups are great for doctors who are thinking about it, or especially who are in the middle of it, trying to figure out how to modify what they're doing.

Dr. Maryal Concepcion: 55:22

For those listeners who have really, Identified with what you've shared or who you have inspired. What is the best way to reach out to you after this podcast?

Dr. Lauren Hedde: 55:33

Um, so probably going to the blog, burden free md. com is a great way to do it. You can, um, Send your information there. Tell me blogs that you're looking for questions that you have. Um, I'm also toying with the idea of sort of offering some site sort of like objective look at people's practices or as you're starting because I really am super passionate about helping doctors get out of this terrible system in a way that's better for them and patients and helping them enjoy. Their lives and their livelihood. Um, so I like the idea of trying to work with people and really, because of what we're talking about is such an individualized practice for each different physician. And it, I want to lay out a lot of the sort of overview of how I think you can do this practice, but looking at an individual's practice, especially if they're three years in or four years in, and they have questions and not working, like I love kind of helping with that kind of thing. So. Please feel free to, to, to reach out and, you know, if, if you have ideas on how I can do that better, I'm definitely interested in it.

Dr. Maryal Concepcion: 56:33

Thank you so much, Dr. Hedy for joining us today. Thank you so much for having me. It was great. Next week, look forward to hearing from another amazing DPC physician. Now I looked through the stats for the podcast since it started and the data is beyond incredible. My DPC story is ranked in the top 0. 15 percent of all podcasts on the globe. Yes, the globe. Every single month over the last two seasons, we are ranking in the top 250 of the Apple podcast medicine chart every month. If you would like to join us in helping spread the word about DPC, consider sponsoring the work we're doing. Go to the sponsorship tab at mydpcstory. com or check out the link in the show notes. Now to our listeners, thank you so much for helping more and more people find the pod by sharing the word about DPC. To our guests, thank you so much for sharing your stories. If you are looking to be a guest next season, apply on the contact page at mydpcstory. com. There you'll also find DPC past episodes, resources, and more. And as always, if you're looking to read more about DPC on the Daily, check out dpcnews. com. Until next week, this is Mariel Concepcion.