Direct Primary Care in Rural Idaho with Dr. Jillian Klaucke

In this episode of My DPC Story, Dr. Jillian Klaucke shares about her journey to practicing Direct Primary Care (DPC). Dr. Klaucke shares her experiences transitioning from traditional insurance-driven healthcare to DPC, emphasizing the benefits of building lasting patient relationships. They discuss the community dynamics in Sandpoint, Idaho, where Dr. Klaucke practices, and her pathway through medical training, including her time in New Zealand and her passion for wilderness medicine. The episode also delves into practical advice for physicians considering DPC, highlighting the importance of planning, financial readiness, and the supportive nature of the DPC community.

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Transcript

Dr. Maryal Concepcion: 1:13

Direct Primary care is an innovative alternative path to insurance-driven healthcare. 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. Jillian Klaucke: 2:01

I transitioned to DPC before I fully realized what it was. I was introduced to the idea by my soon DB partner, and I have been so thankful and so blessed to have fallen into this realm of medicine. I went from being rushed and overburdened and overwhelmed without having continuity with my patients, without knowing their stories or hearing their names to be able to share their photos with me in the office of their recent trip or their new grandbaby. Know their name, know their grandbaby's name, but also to be able to provide high quality medical care to these people and walk with them hand in hand through their journey in life. I'm Dr. Jillian Klaucke, and this is my DPC story.

Dr. Maryal Concepcion: 2:59

Dr. Jillian Klaucke MD is a fellow in the Academy of Wilderness Medicine and is also a board- certified family medicine physician. She is also a Sandpoint Idaho native. She joined Sandpoint Premier Direct Primary Care after gaining experience across the globe, beginning with medical school in Nevada, residency in Billings, Montana, work as an attending physician in Baltimore, Maryland, and traveling for general practice work in New Zealand. Dr. Klaucke has received specialty training in wilderness medicine. And has been awarded again, the Fellow in the Academy of Wilderness Medicine. Wilderness medicine is the practice in resource- limited environments, but may also translate to the office environment for travel planning or recreation advice. As a lifelong lover of outdoor sports, she finds that her advocation and vocation meet perfectly under this educational focus. Dr. Klaucke is passionate about providing whole patient care and helping pioneer a new direction in healthcare, thereby allowing for meaningful lifelong relationships. To develop between doctor and patient. She loves taking care of whole families and she's very happy to return to Sandpoint, Idaho with her husband and two children. Welcome to the podcast, Dr. Klaucke.

Dr. Jillian Klaucke: 4:11

Thank you so much for having me. This is really great. I appreciate your time as well.

Dr. Maryal Concepcion: 4:16

Well, I am excited to have you share your story because for those of you who are listeners who might not have heard of Sandpoint Premier Direct Primary Care, yet the, the world of the Pacific Northwest is a, a very awesome place that a lot of people in my neighborhood have moved to during the pandemic. And so I think that especially with you being where you are geographically, but also getting this influx of people from different areas of the world, I'm really excited to hear what that has manifested in, not only from your time before DPC, but also now in this journey of DPC. So you being a Sandpoint native, what, where is Sandpoint, Idaho and what is the, what is the community like growing up compared to what it is like now?

Dr. Jillian Klaucke: 5:00

Oh, that's a great question. So Sandpoint is a very small town, just 60 miles south of the Canadian border. So in the little skinny part up by the top, we're north of Coeur d'Alene, Idaho, and just northeast of Spokane, Washington, which is our closest international airport. But the town when I was growing up had a population of about 6,000 people in city limits, and now we're nearing 10,000, which is gonna take us out of our category of small town, USA, if we were to pass that number. And the county's population has grown to about 40,000. So. I know those are small numbers for a lot of listeners who might be in big cities, but for us it's been a fairly quick growth. And as you mentioned, a lot of growth during Covid where people were looking for more isolation and, and a rural place to end up in be. So it's a great community. We have a lot of really lovely people here and nonprofits. And growing up in Sandpoint when I was a kid, we had a very wholesome childhood. You know, Ride your bike to the little store to get the candy or show up to see your friends at the park two blocks away. And it was really lovely and I always knew I wanted to come back here and raise my kids here, and somehow that managed to happen. The story unfolds, so, and I'm sure we'll talk about that a little bit.

Dr. Maryal Concepcion: 6:23

It's, it's awesome. I think that, I, I think about this often when it comes to kiddos who are going to elementary school with my oldest my youngest is gonna go in a few months here, but I think about people who grow up in a small town. There's, there's that, that slice of doctors who are like, yeah, and I'm planning on going back to the small town or another small town similar to where I grew up. Yeah. There's something, it's, it's not that there's something in the water, but there's something in the community that is very different than, um mm-hmm. Living in a big city. And it's very interesting. I went to an elementary school where we had 60 kids from K to eight, and I had that small town feel and that's what drove me to do rural medicine. So I love this tie that you have

Dr. Jillian Klaucke: 7:06

yeah. I was really lucky when I was a little kid. My neighbor across the alley was Dr. Lawrence and he was one of the three family physicians in town. And so he was my doctor. He delivered me at our hospital and my little sister, but he was also our friend and our neighbor and his kids were my best friends growing up. So I always kind of knew that that was a possibility for me in this town. But he ended up becoming my mentor later on. And it just, it was another component that made me think, Hmm, this is where I wanna head someday.

Dr. Maryal Concepcion: 7:41

And that's pretty amazing though to have three family physicians just within, your small town. That's, I mean, even just thinking about the numbers that you mentioned, that's really amazing.

Dr. Jillian Klaucke: 7:52

Back then too though, remember these guys were doing OB deliveries and appendectomies, and they were really doing full spectrum family medicine from birth to death plus surgery. And obviously our specialty has changed since that time. But it was really, really neat to be able to see that so close,

Dr. Maryal Concepcion: 8:12

so let's fast forward a little bit, because you went from growing up in Sandpoint to then becoming a physician and we haven't even gotten into your wilderness medicine fellowship, but when it comes to the fact that you were, in and, and I missed in your bio in California, then Nevada and then Montana and then back to Idaho. Mm-hmm. Tell us about your your journey in choosing to be a family physician. Because when we see, when we see something as a young child, very possibly, I could, I could easily see how someone could take that persona and take it with them, but then once we hit medical school, yeah, there are people who change in terms of the trajectory of, I know I saw this and I love this coming in, but, so tell us about your journey to becoming a family physician.

Dr. Jillian Klaucke: 9:03

Great, great question. Not only through, being in the same community as my doctor, Dr. Lawrence, my grandfather was a family medicine physician at the University of Minnesota. He was actually really helpful in getting family medicine designated as a specialty in the sixties and seventies, and spoke to Congress to try to get rural physicians into rural areas. So he founded the RPAP program, which is a lot of what rural rotations in medical education is based off of now. His name was Jack Verby and he was pretty powerful guy in my life as well. And he always encouraged me and said, you know, you really should be a family doctor when you grow up just like me. And I said, oh, okay. Six years old or something. And it was really funny that I was lucky enough to remember that, but then end up ultimately having the grit and gumption to do it. And just like you're saying, sometimes people change their trajectory in education. When I went to medical school, my first rotation as a third year was plastic surgery. And I said to myself. I'm gonna be a hand surgeon. Look at this. This is amazing. People come in with disability and they're fixed and they can move their hand after they've have been stuck inflection for three years or whatever that looks like. So that was my first rotation. Then I was on VA general surgery rotation. This is amazing. I am gonna be doing these thyroidectomies. I love these hernia surgeries. This is so cool, and so on and so forth. Until I finally got to my last rotation of third year, which is family medicine. And I went, okay, you love everything. This makes so much sense. Welcome home. And it really just felt right to me. So it, it's an easy decision to head. Back towards family medicine, which is what I had intended upon doing, entering school at the University of Nevada. They really do put a focus on rural medicine. Nevada has a lot of small towns with a big need. It's not just Reno and Las Vegas, but they also accept kids from the Whammy program, so Washington and Alaska and all those programs over the west. And they want to get those students and ultimately residents back into rural areas. And family medicine is a great pathway to do it. So when I got to my third year rotation, I went, oh, yeah, okay, this is where I'm supposed to be. And started interviewing and ended up thinking a little bit more about where do I really wanna be, because I had some great options for where I wanted to do my residency training. And I thought, well, what's my goal? I still wanna get back and work with Dr. Lawrence. So I did a rural rotation with him and another practice group here as a medical student, and then again, as a resident, and started talking to them about jobs. And then I didn't come back right away.

Dr. Maryal Concepcion: 11:48

it, I, I love these little, segues to our eventual path of DPC, but you know, when you're at this point of you get the chance to rotate with somebody who you see yourself being in the future Yeah. And then you're like, oh, I am finding myself over here. What was it that, because I'm assuming when you say that, you mean Montana and also New Zealand mm-hmm. Really far out of Sandpoint, Idaho. But how did you, how did you incorporate those, points on your journey to DPC?

Dr. Jillian Klaucke: 12:19

Yeah. So at the time of choosing a residency, I thought, well, you know, I've always had the goal to get back to Sandpoint, or at least a town like it, and the medicine, the further away I was from the Pacific Northwest, the different, how different was it? And so I ended up thinking, well, what can, where can I go that I'm gonna get good training and it'll be a new life experience for me? And Billings just had all the right criteria. It was also the only residency at the time in the state of Montana, and the only other residencies in Idaho were in Boise. Now there's one in Coeur d'Alene. There's a residency in Missoula. So the options now are much greater. But I just thought, well, I'm gonna get closer to that type of patient and pathology and mindset that I am gonna ultimately, hopefully see in standpoint if I'm able to land there. And then I was closer to my folks and closer to my family. And that was important too at the time. So I went to residency in Montana and in my third year I did a rotation at Big Sky Montana. And if any medical students are listening in their third year, take a look at that as an option of residence too, because it's a month long ski rotation. So you work seven days a week, you have to be in the clinic for three hours. Back when I did it, it came with a ski pass. So you get to ski half the day and you get to work the other half of the day. And lo and behold, there is a very good skier and capable and handsome. Orthopedic surgeon to be that I met on that rotation and we just fell in with each other and there was no questions after that. So I met my husband when we were there at Big Sky, sharing that rotation and he did his residency at Shock Trauma at the University of Maryland in Baltimore. He's from the East coast. And I said, well, that's great. I love you. This is wonderful. But I took my first job out of residency in New Zealand because I needed a break. Residency. Training's difficult. We, for those of us who have been through it, it's fairly intense and our patient population was very difficult. So I ended up going to New Zealand and working in another rural clinic just outside of Christchurch on the way to the West Coast. Just a beautiful area. Lots of farmers, lots of adventures. It was really, really fun. But ultimately because of my relationship with my husband, I kind of diverted a little bit before we came back to Sandpoint. So. He did his residency in Baltimore. So after being in New Zealand for most of his internship year, I moved out there. And then when he finished his residency, I think he may have been a little jealous because he was going to work. I would talk to him at nine o'clock at night and go to bed and I'd sleep all night and I'd wake up and I'd go do my shift in the little rural clinic. And they have morning and afternoon tea and afternoon tea was a built-in break and I would call him on my afternoon tea on my WhatsApp or Zoom or Skype, I think it was back then. And when I had called him at nine o'clock at night, he was driving to work. And when I called him at three o'clock, he was driving home. And so on my days off, I'm going surfing or climbing or skiing or doing all these fun things. And so, and I think that propelled him to want to go to New Zealand as well. So he ended up taking a fellowship in pediatrics and sports medicine and we were there as a family with our two young children who were five months and just over two years when we moved there at the time. And we spent almost a year and a half in the country. And I worked in Auckland in a couple different family medicine GP groups. So

Dr. Maryal Concepcion: 15:58

that's fascinating. And I just, I think about some of my classmates in med school and then some of my husband's classmates in med school who went to Ortho and they were Q2 and I was like. I don't understand what you just said. And like those of us who've been through residency, you know what that means and that is every other day you're on call, which is absolutely freaking brutal. And to be yes to, to gosh. Mm-hmm. And you just mentioning nine and 3:00 AM I mean, like that's I'm sure there are other people blanking out on how impossible that sounds because it is impossible to maintain a life livelihood like that. Yeah.

Dr. Jillian Klaucke: 16:32

Well, duty hour limitations started coming in to be just before I started residency, so it was still a new concept back then. He would work a hundred hour weeks. I would work 80 plus hour weeks, especially on the hospital as service. And it takes its toll. So for me, New Zealand was a fresh, was a breath of fresh air. And then going to Baltimore, I got the experience I think I really needed as a young attending to have the courage and the just the confidence to start a DPC practice when we ultimately ended up

Dr. Maryal Concepcion: 17:03

back here. So awesome. I love it. So I want to ask here, because the last person who was on the podcast who had gone mm-hmm. To New Zealand was Dr. Amanda Dorn Feld. And she went literally in, in plans to, stay in New Zealand a bit and then come back and then the pandemic hit for her. Yeah. I remember her sharing how even in a, in a different health system, um mm-hmm. She was shocked at, at how like common guidelines, like colonoscopy guidelines were not even a thing when she was in New Zealand in 2020. And so I'm just wondering, given that you, have this exposure to rural medicine, you went to a pretty well-rounded residency and then you were able to practice even in a different country. What types of things made an impression on you practicing, especially in a different country that you brought back to your DPC later on? Great question.

Dr. Jillian Klaucke: 17:56

I think practicing in New Zealand, which is a small country that has a structure that allows socialized medicine in and of itself is a really great model. I. People had access to care and it was affordable care. And New Zealand also has the A CC. And forgive me if listeners have heard this before, but it's an accidental policy for anyone who's in New Zealand. Anytime so the surgeon does surgery on the wrong hand, or you slip and fall on the ice at the mountain, or you get a bee sting and it gets infected, all of those are considered accidents and covered by the a, CC. So that was great because people in New Zealand were very self-reliant and they would troubleshoot problems. And if they hurt their niece slipping on the ice, they would go see the physiotherapist or what we would call physical therapists before they'd come see us as physicians. I really, really liked that access. So being able to call your doctor, come in and see him, that was great. It was great. On a primary care level, it is not great if you need a hip replacement. I remember I had a patient, this is in 2012, and she had had rectal bleeding and I did an anoscopy procedure on her in the office, and there was a large polyp. It was about three centimeters. It was in her rectum, and I had to send a referral. They, for the most part have a universal EMR. Just there's a couple variations. And the GI team declined my request for a colonoscopy. And I don't know what the hiccup was, but I remember having to get on the phone and saying, no, I saw this polyp. You need to take this out. This is a cancer until proven otherwise, you guys, and they were just so overburdened by volume and use that the wait times were incredible or they would prefer to give advice over the phone or via a letter rather than be able to actually integrate these people into a very, very busy schedule. So I didn't like that part. My experience in the rural clinic was interesting too. Same as in Auckland actually. I worked in two GP practices in Auckland. I did not have a nurse. My exam room was my office. I had a curtain across the exam table that patients rarely if ever used, if we needed to do a breast exam. They just took their clothes off and I didn't leave the room. That's just how it was. But I only had 15 minutes. So any vital signs I wanted, I had to take them. And any problems we needed to cover it was, you get one, and if you have more than one problem, you book a double appointment, which is double the cost, and if you need to do more, you need to come back tomorrow. Now the accessibility was there and the GP office, especially with a locum, because I didn't have my own continuity patients, but that time crunch, I also did not like, because I wanna talk to my patients and get to know them. And so if I'm just seeing a kiddo to check their ear before they go outta town for the weekend, you can do that in 15 minutes. But if you have somebody who's complex, you just can't. So there's pros and cons to how that worked. I, I really enjoyed it a lot and if anybody's considering doing it, I would suggest it because it, it, the other thing that it showed me was that you can have work-life balance, especially after residency. My jobs were shift work, sessional rates, sessional wages, and I could choose what hours I wanted to work. Typically it was eight to noon or one to five, and it was as many shifts as I wanted to with the ability to take call if, if that was something appealing. And sometimes I would do fill in work or nursing homework. Nursing homework in New Zealand was a joy. It was surprising how much I loved it because they don't have all the Medicare boxes to check. And you had a nurse that you partnered with and you would make rounds together and you would troubleshoot the problems. And the patients had incredible stories. We had one couple who celebrated their 65th wedding anniversary when I was there and showed me their letter from the Queen congratulating them. And it just, that was really a fun part. So I think that that made, you wanna hear more stories, and I brought that back to DPC too, so that when I see a patient here. If I know they're chatty, I just book'em in for an hour and we, and sometimes they say, it seems like we should just get a cup of coffee and sit down and talk, which is pretty fun.

Dr. Maryal Concepcion: 22:28

I love that. And I, I love how you can so see the similarities when it comes to accessibility, when it comes to having a relationship and it come, when it comes to having the time you need with your patients. I mean, it's literally wow, why does that sound familiar? Oh my God, that's DBC. That's amazing. So I love that. Now let me ask you here, because I don't know the answer to this. Whereas in the states, we have to find malpractice for, you know mm-hmm. Students state who're practicing in, did you go through a particular like company or did you have somebody help you set up everything, including malpractice when you were doing locums in New Zealand?

Dr. Jillian Klaucke: 23:51

I did not need malpractice insurance at all. So that was covered under the a CC in New Zealand. So I could elect to get additional coverage or do additional training if I wanted to, but I did not elect to do so, and it hasn't been an issue. I think when we're young doctors, sometimes we do a little bit of CYA medicine. I think as older doctors, we do that too, right? Because there's always a scenario where you don't wanna get into any trouble. But even just taking that heat off as a young graduate felt amazing.

Dr. Maryal Concepcion: 24:24

totally. I can absolutely see, the, I just picture like the person who is really scared to open a DPC because they are mm-hmm. Not sure about malpractice, even within the states this is not even foreign. So I, yeah. So that's great. Great to know. Mm-hmm. Now, how did you guys then migrate back to the States and then to sandpoint after your time in New Zealand?

Dr. Jillian Klaucke: 24:49

Well, before we left for New Zealand, my husband was finishing residency and we sold everything that we owned and we packed into 200 pounds and a couple of boxes that shipped on Amtrak and a car full. That was it for four of us. It was, it was wild. And while we waited for him to finish his residency and study and take his board exam, we moved in with my mom and dad in standpoint. He ended up talking to the local hospital and they said, yes, we have room. We'd love for you to come back. Can we hire you as an orthopedic surgeon? Which made me say, this is actually feasible, but we can't come back until we're done in New Zealand. That's gonna be at least a year, if not longer. And I started to talk to all the family practice options in Sandpoint. One was a federally qualified health center, one was a private practice, and they're great. There were people that I had met as medical students and as residents. One of the doctors in the private practice remains my neighbor, a different neighbor than Dr. Lawrence actually. And so it's an, it's a small community and I was ready to take a job with one of those practices until my mom said to me, Hey, my coworker said you should go meet Dr. King. I said, who's that? I hadn't heard of him. He'd been doing DPC for a couple years, but he had been doing general practice for many in the community. I said, oh, okay, I'll go talk to him. And I remember sitting down with him in his office and him telling me what is DPC and how his practice model works, and saying, this isn't real, this doesn't make sense. No one talked to me about what DPC was or even the possibility in residency. And I said, can I come back tomorrow with my husband? And we came back the next day and he told my husband, and my husband looked at me and he said, this is what you should do, because he was gonna start his job and it would allow me to start and grow a practice from zero. So that was a blessing at that time. But also, Dr. King has been such a lovely and supportive partner. I really couldn't have gotten any luckier with him especially to start and grow a DPC in a thriving model that was already doing fairly well. So we ended up contracting and negotiating over FaceTime while we were in New Zealand and kind of getting a plan together. So that when we came home, Jonathan started his job with the hospital. I had about a month to transition my kids into their preschool and daycare, but also be their mom get settled into our new house and then slowly start chipping away at the building blocks of the practice and starting to see new patients.

Dr. Maryal Concepcion: 27:31

That's awesome. And I, I wonder here, just because. Dr. King is in practice. You're learning about DPC, you guys are coming together over, that's amazing how you guys connected. I love that. But when it comes to just knowing that it was going to be okay for you guys to partner, I wonder about that because, there's a lot of people who are like, oh, now more people are wanting to join A DPC versus starting their own. Mm-hmm. And so when it comes to, any high level tips that you have for feeling each other out to see, is this a good relationship to, to go into, to try?

Dr. Jillian Klaucke: 28:07

Yeah. I was probably pretty naive at the time. I didn't really know, I didn't really suss him out. But what made sense to me at that time was that he and I were growing parallel practices. So he had his own business in LLC and he hired me on as a 10 99 contractor, and then I was able to create my own PLLC and grow next to him. That meant that in the first month when I had 10 patients. I had 10 patients, but that meant when I was full, two and a half years later, I was full. And over that timeframe, we were able to really make our office more efficient and trim down some of the costs that we didn't need. We ended up hiring a really wonderful medical assistant who I always tease is worth her weight and gold. She's been really helpful in getting us more digital or using our EMR or lab interfaces to the best of its capabilities. So it's been a growth project, definitely, and I wouldn't turn back. I, I don't think I'll ever enter traditional medicine ever again, and I would encourage people who are thinking about DPC to look closer. Now as far as finding a partner, that has been an interesting challenge. So my partners thinking about retiring and. It is been tricky. It's been tricky because there's so many options. Just there's so many places to get your news. Can you get it on social media? Should you get it on Fox News should be reading the paper or phones in the morning when NPR breaks there. Morning Edition, there's so many options. There's also so many options for where to look for and recruit a physician. Is it talking to the local residencies? Is it recruiting online? Is it actually using a recruiter? Is it by word of mouth? We've had a number of doctors come through looking for work, and we've been pretty close a couple of times to have somebody join us and for one reason or another, it hasn't worked out whether they weren't ready or we couldn't offer them a full practice out the gate and they didn't wanna take a pay cut. And that's really hard if you're the primary breadwinner to say, okay, I don't have a full practice and I'm not gonna be making the same money I was in a traditional hospital practice. But it's so worth the weight and it's worth taking that hit because in the long run, the work life balance is so beautiful and you're your own boss and you can make your practice be whatever you wanted it to, to be.

Dr. Maryal Concepcion: 30:46

I think it's so important that you mention that, especially for those people who are in that situation and they might be able to take those words and brainstorm differently in order to make this happen. Mm-hmm. To be a DPC doctor. So I think that's, that's wonderful that you, you shared that when it comes to the community, given that you were from Sandpoint, you're you, you even went back in a buffer and stayed with your parents when you initially moved back. Were you, known in the community in terms of oh my goodness, I'm so excited that she's coming and she's gonna be a doctor. I'm signing up today. Or did you have any just because I think of with Dr. King already there like, did you even have your own, but what is it that you do type of question?

Dr. Jillian Klaucke: 32:12

Yes. I think all of it. So there were some folks who had been waiting for me to come back and there was a wait list when I came. Right. So the first month I had 10 patients there. Surprisingly, with the growth of the town, there are a number of patients, I don't know, I've never met them. I've never seen them in town and they've lived here for 10 or 15 years. I was gone for over 20 years before coming back to set my practice up. And then there's some people that I'll see in the office and go, oh wait, what year did you graduate? I think you went to school with so and so. Do you remember? And that's kind of funny. I actually have a standpoint spiel I give to the locals that I recognize because small towns are small towns. And I say, hey, we went to high school together and we know a lot of people in the community jointly. I just need you to know that what happens in this office stays in this office. We take confidentiality very seriously. This is a safe place for you. I'm not going to talk about things that we talk about anywhere else. And if I see you in the community, I want you to come and say hi to me first so that you feel comfortable and I know that it's okay to give you that acknowledgement. And it happens. It happens in the grocery store, it happens at the farmer's market. It happens at the kids' sporting events. And sometimes it's funny'cause people will come up and start talking about something that is probably not appropriate to talk about in a room that's full of people. And sometimes people will call and say, or come over and say, Hey, I need to call you. I need to come in. And then I go on my phone really quickly and I find them in my record and I put a task to my assistant and say, please, please call them for an appointment so that we can get'em and have'em come, come in when they need to be seen.

Dr. Maryal Concepcion: 33:58

I love that. And it's already hitting on point, even just in your opening days about accessibility for your patients. So that's awesome. Yeah. And when it comes to this idea of what do you do as a, like what is DPC and also this influx of patients into the community or in influx in members of the community, I should say. Did you find anybody who was like, I already had a DPC doctor in the state that I came from and now I want you because you do DPC specifically?

Dr. Jillian Klaucke: 34:27

Yes. Yep. A lot of people will self recruit to the model because they have experience with DPC. I find my role here in Sandpoint is variable. So I have some Medicaid patients in my panel. I have many people who are seasonal workers. We're a four seasons town with a ski hill and a lake. And they come in and they say, I make a good wage most of the year, but because I work at the ski mountain, I don't get insurance or because I work doing landscaping in the summertime, I make a great wage, but I, my job doesn't provide any sort of benefits. And so those folks may not qualify for the state funded premiums or they may qualify for a catastrophic plan common. This happens in DPC and they come see me. And I think more so what happens lately, now that my panel is fairly full, is it's patients who no longer trust in regular healthcare and they feel that their doctor doesn't have time for them or their doctor doesn't listen. I get that. When I was in New Zealand and I saw one patient in 15 minutes and took all my own vitals, you know what I did in order to man maximize that time, I took notes on my computer and typed the note. As we were talking, I essentially took dictation. How present can you be in that moment if you're doing something like that? And so patients will have heard about our model and that we don't have computers in the room. We sit with a clipboard and we listen. And if you come in with a list, 15 things long, we're going to just say, can I see the list please? And go through it one by one by one. And Frazier and I are very compatible in that manner as well. So our practice styles are pretty similar when it comes to providing patient care and, and I think you can only know that after time in the saddle with somebody because you can ask them, Hey, how would you approach this problem? Or do you get your notes done on time? Or What was a difficult scenario with a coworker? All those interview questions, but you just don't know until you're doing it.

Dr. Maryal Concepcion: 36:37

Very understandable. And I definitely think that there's lots of, great examples even on the podcast of people who have partnered together or people who are married and practicing together. It's, it's, it's definitely you. I, I am completely with you in that. You don't actually know until you, you try it. And I think that the way that you guys did it, how you were at 10 99 coming on, I think it's a very reasonable way to, explore a relationship without getting married on day one, so, so to speak. Yes. So, yeah. That's awesome. Yeah. And when it comes to just, I wanted to call out one tagline on your on your website, because this really, for me, it also, it makes you like super excited to ask you about your wilderness medicine fellowship. Yeah. That it, it says that you guys are delivering a different kind of healthcare. And so as you've spoken about how people are, really leaning into the way that you deliver care, the relationship, the really personalized focus of every single visit how does wilderness, how does your fellowship in wilderness medicine play a role in all of this? Because especially you're in a place with a with a ski slopes and a lake.

Dr. Jillian Klaucke: 37:41

Yeah, So I think that tagline on the website, when we first started doing DPC in Sandpoint Frazier, I think started in 2015. And I started in 2018. We really were some of the first practices in the United States and now there's so many people are headed to the DPC direction. So part of it was talking to that. Right. And is DPC really a new frontier? No, it's an old frontier. It's the medicine my grandfather practiced in 1965 without insurance companies playing a role. But when we talk about wilderness medicine, how does it integrate into my practice here? A lot of it has to do around travel planning. So I'll have travel consults. I will have people who will return from travel with rashes or an injury or something that was managed overseas that needs more TLC or care. And then I have a lot of people out there having fun. So they have a tibial plateau fracture skiing, or they tear their biceps water skiing or they have a tumble on their mountain bike and they need to get wound care. And we have'em come in every day for their giant abrasion or whatever that looks like, and that's pretty fun. But wilderness medicine is medicine in austere environments. So realistically I'm using wilderness medicine more so for the fun stuff. But one of the themes is what do you have and what do you need and how can you make what you have, meet your needs, even if it's something. Not that appropriate. For example, I gave a talk to the residents just last week down in Coeur d'Alene on casting and splitting in the wilderness as part of one of their afternoon didactics. And I said, look around, what do you have? I picked up some sticks off the ground of the park where we were at. I pulled my backpack panel out of the backpack. I use to have my gear, Hey, you can make a pretty good splint out of a backpack panel that's padding for those two sticks that you're gonna wrap with a t-shirt. That's not a Sam splint, that's not a, thumb spike or wrist brace, which we don't hike with, but it's pretty fun to, it's pretty fun to integrate wilderness medicine, maybe not formally, but in those other tangential pathways.

Dr. Maryal Concepcion: 40:03

And I just think about, like the times that I've talked about practicing overseas specifically when it comes to female exams and like the things that, we've had to do on, whatever makeshift thing that we could do for Pap Spears in the Dominican Republic. Like mm-hmm. I think about the times that like this is nothing necessarily to do with how helping. With, with particular diagnosis or treatment. But it's like when the electricity goes out and you have to use a headlamp in your clinic. Yes. And like you make a a light, you make light of it, rather than be like wanting to die and, and sweating.'cause you're so nervous. You're like, what is my patient gonna think about me? Like I, I, I, I think that these these things that we have in our pocket ready to go are also so great for family medicine because we never know what the heck we're gonna see

Dr. Jillian Klaucke: 40:50

right. Or they might come in saying, Hey, I hurt my wrist, and then all of a sudden you're having a totally different conversation. We've all been there in our day-to-day practice. Okay, let's break that down. Good thing we've got extra time today.

Dr. Maryal Concepcion: 41:02

Absolutely. Oh my goodness. And when it comes to the, when you talk to the residents, I just wonder do they lean into your way of practicing being a DPC doctor more because you're bringing this oh my God, she's a family medicine doctor and she's doing this stuff with her backpack. This is amazing. What kind of doctor are you to be able to do all of this?

Dr. Jillian Klaucke: 41:24

I would like to pull them and see what they said, but I did plant the seeds with the interns and say, Hey, you guys come, come up and rotate with me. Come check it out. See what it's like. Because I wish I would've had someone say that to me. I wish I would've had in some point in training someone say, Hey. Running a medical practice isn't about signing a contract and becoming an employee. You need to think about hr, you need to think about savings, you need to think about retirement, you need to think about efficient business efficiencies. How do you find a good accountant? All of the things that as you're growing your DPC practice, you're gonna be forced to learn. But it's nice because you'll have time to learn it too, if you put your mind to it and work hard.

Dr. Maryal Concepcion: 42:07

And especially just thinking about how you started with, a wait list of 10 people, which is awesome, but it's also super more manageable than 200 people on your wait list. So I think that that's, that's awesome. I love how you mentioned your sandpoint talk that you give to people who you may have known, growing up. Yeah. When it comes to just maintaining relationships, what do you guys do? In order to like, make sure that people know it's an open door, because I like, I don't know if you get this in, especially, you might see it more in the people who have migrated to Sandpoint, but I will be like, you pay me every month and you could have called me for that thing. That's not like I, I had a, a caraway cant, and it's like my patients are like, yes, we were waiting in the urgent care for eight hours and they told us that it's an emergency, we need to go to the emergency room. And I'm like, oh my gosh. Like this, this type of stuff where we have to remind our patients like, Hey, hey, remember I, I'm your doctor over here. Yeah. Do you do what do you guys do to lean into this? We are here to build relationships with you.

Dr. Jillian Klaucke: 44:41

Yeah. So when we have new patients come in, I give them another spiel. In part of that spiel is, you are going to get my business card with my emergency after hours cell phone, and I want you to call me. In fact, most of the time I kind of get grumpy with my patients because they don't call me and I say, why didn't you call me? You have your cell, you have my cell phone number, and I have a spectrum of patients. I have one patient who says, I am paying you each month for your cell phone number. So if I ever call it, I want you to answer. And I don't see those guys. I can think of at least three of them. And then I have patients who I see every week or two, and that's okay because they're in crisis or they're dealing with a new disease or a new diagnosis. And I say, if you have problems tonight, I want you to call me. And again, they usually don't call me and it's fine. But that's one of the fears that people have. Patients have the fear, how do you ever get time off? You're on call 24 7. I don't ever wanna bother you. But I also have young doctors or nurses or other clinicians in the community say, I don't understand how you do it, being on call 24 7. And most patients are so respectful, but we will reach out to them. So using our EMR, we have a series of future-based tasks so that we keep tabs on them and we don't drop'em. So if somebody is due for their follow-up imaging of an ovarian cyst, we have that reminder come up six months later and we say, we've sent your order. You're due or you're due for your thyroid labs. We just changed your dose six weeks ago. Please schedule a non-fasting test, or it's been a year you're overdue for your yearly labs, please call to get in for an appointment at your earliest convenience. And I think people really like that because in this busy world we have things coming at us and push notifications all the time. So we're a kind of used to it, but B, sometimes overwhelmed and we forget about ourselves in the midst. And having a little bit of a reminder or more of A-T-L-C-I think works and helps.

Dr. Maryal Concepcion: 46:55

Absolutely. And I think that it also, this, this leads me to my next question, that that level of care has probably also led to you guys being full as a practice. And so I'm just wondering, yeah, I'm just wondering here when it comes to dealing with, Hey, are you open? I'd like to join, what do you do? Because right now you're full. I know you mentioned Dr. King may be looking at retirement soon, but like mm-hmm. What do you do to, maintain those leads?

Dr. Jillian Klaucke: 47:26

W we've done variations over the years. When Dr. King first started talking about backing off to part-time, so he and I were full together at the same time, and we actually just closed our practice and online we said, if you're interested in joining us, please call. And we screened our patients to come in because some people will try to come in and they'll go, wait, what? It's a year contract. I thought it was$60 for one visit. No, that's not how it works. And then we've wasted everybody's time. And then some people still are confused with the fact that I don't take insurance, but I'm an ordering and referring provider for insurance. And, and we try to clarify those things. So there's a, there was a first pass on the phone then for a while as his numbers were dropping down and I didn't have patients just do natural attrition with people moving or having, life ending situations. I dropped down a little bit, but at the time I didn't really mind because my kids were in school and there's all of these other things happening, but. Recently we have reopened our website so people can sign up online. We tell them when they sign up, we call'em that same day. Welcome to the practice. We are so happy that you've joined us. Just so you know, your new patient visit is three to six weeks out, but if there's an urgent matter that comes up, we can get you in for a quick visit before we do the full hour long visit. And that helps. And we've had a slow trickle of patients. I am really optimistic we're going to have a provider join us this summer, fingers crossed, but if not, I'll ping you so you can say, Hey guys, remember that interview. Go talk to Dr. Cuffy. And so when that happens, that's going to give us a whole different dimension because we'll have my partner, Dr. King, who's part-time and then someone else coming in part-time too, and that'll allow some more growth. Idaho's a very interesting state to practice medicine and unfortunately, what's under threat right now is the Medicaid expansion that was passed by popular vote a couple years ago. The citizens of a state voted for and passed Medicaid expansion, and now it's back on the chopping block. And if that happens, huge number of patients are gonna lose their insurance. And I'm not sure what we're gonna turn to. Our FQHC is bursting at the seams. There's no OB or GYN care in my community. There's actually a podcast about that on this American life. One of our OBGYNs was interviewed. It's heartbreaking. And so it'll be interesting to see where things go in our community and in our state with regard to what care is available and how much people can access it. And I think DPC is gonna potentially become even more appealing if things go the wrong direction with what's available for care for those who are really at need.

Dr. Maryal Concepcion: 50:24

I absolutely agree with you that this is why DBC is so appealing. So I love that. Mm-hmm. I love that you're doing this. I definitely would say like I am, like sending all the good juju. Like I hope that that person starts working in the summer because not only does your community need it, but also, what community does not need primary, more primary care access, but also, just to, to be with you and Dr. King who are so like-minded already with, just being in the community and taking care of them, taking care of your patients in this relationship focused way. So I love that. And, I, I think about like the, the next thing that I wanna ask is can you give, the audience an example of like, only in DPC? Could this have happened?

Dr. Jillian Klaucke: 51:08

One day, this was probably four or five years ago, I had a patient come in to see me and she had seen me a few times. Relatively new patient, six months in something, something like that. She had a couple things going, a little high blood pressure, a little last reflux, a little bit of anxiety. But she made her list'cause it'd been a while since I visited with her and her list. I think I. Was about 13 items long and we started going through the list and I was very glad I had the extra time, which I went over, which was not a problem because our patients get it. They know that if I'm with them and they need time, I'm gonna give it to them. And if I run a little bit late, we're either gonna call or text them or that's okay. Our wait times are never usually more than 15 or 20 minutes. Oftentimes we run right on time and we got to number 13. She says, oh, I have this spot on my leg. Can you please take a look at it? And I said, sure. I was not expecting a gnarly 1.5 centimeter raised pigmented lesion that was a melanoma until proven otherwise. And all I thought was this should have been number one. And I said. That needs to come off. I'm going to do a punch biopsy. I'm sorry, I know this appointment's taking a little longer than we both anticipated, but we're gonna do that right now. And I called my assistant and I said, please set me up for a punch biopsy. And we took a piece. Thankfully it wasn't, but I ended up removing the entire lesion because I took a piece and we could have missed something. And she was so thankful. She's also glad that it was gone because it was fairly unsightly. But that could only happen in DPC, it was slowly and systematically get through that list and you get to number 13 and then have plan in place that you can execute right then. Because in my traditional practice when I was in Baltimore, I was an employed physician. I was one of nine in a hospital based practice, clinical practice, outpatient. And my wait time was four months long. And if patients were sick, they never saw me. I did not have time to do anything like that. I had 20 minutes per patient. Oh, and by the way, if I had any no-shows the week before, they would count up how many no-shows I had. So if I had one no-show per session in the morning and in the afternoon, that would be 10 per week. And I would somehow have to overbook myself by that percentage of no shows.'cause they probably were gonna no, show me on me again. And now all of a sudden my work hour it, I would put on roller skates and it didn't mesh with my personality. And that could have never happened except for in this moment in DPC it happens like we joked about at the beginning. They come in for wrist pain and you're down the rabbit hole of something totally different by the end. But very important nonetheless. And I think that builds trust when patients feel like we can talk about things. Or I had a patient who came to see me as a new patient and we were talking about something very benign acid reflux. It wasn't until 45 minutes into the visit that we got to the real reason that she was there. And it was emotional and traumatic and contributing absolutely to her reflux. But if I would've been in my new patient 20 minute visit, who knows? And my followup would've been six months later and good luck. So DPC just offers that time and, and I think that's one of its greatest strengths.

Dr. Maryal Concepcion: 54:49

And I love it. It's, it's going back not only to what you were picking up on when you were in New Zealand and mm-hmm. Just, your time prior to that, but also, I, I just wanted to call out here how you said I'm sorry, your appointment's gonna take a little longer than then, you thought it's not that like the patient is pissed off because you can't spend enough time with them. You're, you're saying to the patient like, I'm so sorry. We're gonna take a little bit longer here. And that's, that's totally, I, I don't like, I, if I ever said anything like that in fee for service, it would be because like, something needed to be addressed. But it's like you also have this massive guilt of you're putting everyone else behind. You're never gonna be done on time. You know that everyone's gonna be mad at you as soon as you see them in their next patient in, in their next visit. Yeah.

Dr. Jillian Klaucke: 55:36

Yeah. You're gonna be late to pick up the, your children at the daycare, you're gonna get a fee because you're late, then you're gonna hit traffic. I mean, it just all snowballs.

Dr. Maryal Concepcion: 55:46

Crazy, crazy. You talked about how your husband and you sit down with Dr. King and you, you're like, this is really amazing. I, I think I wanna do it. And we talked a little bit about potentially financially preparing, knowing that if someone is the primary breadwinner, hey, this is one way to think about doing DPC. But I'm wondering in terms of other things, other things that you would recommend people thinking about if they're either hybrid, there's some DPCs that are still hybrid mm-hmm. That have not opted out of Medicare or the people who are thinking about DPC in terms of, residents to people who are 20 years in, what other things would you just mention to people or call out to people to really think about work life, balance, finances, and, and what else? Because I think that, again, you are a rural physician like myself, you're a person who really loves the accessibility, the time with patients and the relationship. So anything else that comes to mind?

Dr. Jillian Klaucke: 56:45

I have found the DPC community in general to be very, very welcoming. So there are 3D PC practices south of me in Hayden, which is about 45 minutes in post falls, which is about an hour. And we got together as a group of doctors when I first moved here and had supper and talked about it. And if you have any interest in DPC, if I have someone cold call me and say, Hey, I'm so-and-so, and I live in Florida, and I just wanna hear more about that, I can schedule time to talk to that person. And I'm not gonna be like, Ugh, why did you get in touch with me? It's gonna be more, this is my baby. I'm so excited about that. And your life is going to change. You can't understand how much until you're doing it. And some of those harnesses are off of you. For example, the time limitation or the fact that my kids have soccer at four o'clock on Mondays and I block myself out at three 30 so I can take them to soccer. Or I block myself out on Tuesdays at two 15 for half an hour so I can pick'em up from school because they don't have anybody to go get them And that just creates less stress. We have a lot to manage as physicians. We have a lot to manage. If we are part of a family, we have a lot to manage, just to stay board certified or to keep up with your CME. And DPC allows you to carve out the time and space to do those things. But I think your question is, what else should people keep in mind when they're thinking about DPC? It's not a quick and immediate reward for most people. It's a slow burn, and you need to think about what your five year and your 10 year goal is and what your plans are. And you need to be committed to the model because if you say, oh, I'm gonna start a DPC and you're in the red for the first six months and barely breaking even for the next six, and then kind of turning a profit for the next year, depending on what your student loans are like, or depending on what your other obligations are. You have to put the time in and do the hard work and take the risk, and that's really scary. But if you have a five-year plan or you have a 10 year plan, or okay, I got this loan at this much interest percent, if I pay this down quickly, then that goes away and I can use, you have to be, you have to be thoughtful in your approach to starting A DPC and have a good idea of where you're at financially and where you are within your practice. So someone fresh outta residency, starting a DPC practice, you could do it, it would be a much steeper slope to climb than someone who maybe has a little bit of savings or can join an already existing DPC or has a practice that's going. So you're already in a community and you have 2000 patients. You might take 200 with you. That's kind of the quote. If you see, you might take 10%. So you gotta, you gotta play the long game a little bit.

Dr. Maryal Concepcion: 59:59

thank you so much Dr. K Clarky for joining us today. Your episode is coming out almost, end of the, or middle of the second quarter. It's like, it's like that extra, boost in, in energy just hearing your story. So I'm so grateful for you sharing it

Dr. Jillian Klaucke: 1:00:13

Yeah, you're welcome. Thank you so much for having me. I feel really, really thankful every day to be part of a DPC practice and to be a mom, and to be a physician, and to be in the town that I'm in and the community that I'm a part of with that training. So I really appreciate you giving me time to talk about all of that this afternoon and, and share my story.

1:00:36

Thank you for listening to another episode of my DBC story. If you enjoyed it, please leave a five star review on your favorite podcast platform. It helps others find the show, have a question about direct primary care. Leave me a voicemail. You might hear it answered in a future episode. Follow us on socials at the handle at my D DPC story and join DPC didactics our monthly deep dive into your questions and challenges. Links are@mydpcstory.com for exclusive content you won't hear anywhere else. Join our Patreon. Find the link in the show notes or search for my DPC story on patreon.com for DPC news on the daily. Check out DPC news.com. Until next week, this is Marielle conception.