Inside the Fight for Equitable Healthcare and Physician Freedom with Dr. Michelle Cooke

On this episode of My DPC Story Podcast, Dr. Michelle Cooke, founder of Sol Direct Primary Care in East Point, Georgia, shares her inspiring journey from burnout in fee-for-service medicine to building a thriving direct primary care (DPC) clinic dedicated to Black women’s health and wellness. Dr. Cooke discusses overcoming the challenges of the broken insurance-driven healthcare system, embracing entrepreneurship, and honing her practice’s mission to combat health disparities in her community. She offers valuable insights on scaling a DPC clinic, effective patient-centered marketing, hiring strategies, and leveraging technology and EHRs to streamline care. Listeners will learn about the impact of DPC in underserved areas, the importance of mindset shifts for physician entrepreneurs, and how personalized, transparent care empowers both doctors and patients. Tune in for actionable tips and inspiration for those considering the DPC model or seeking to revitalize their medical career.

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Transcript

Maryal Concepcion, MD: 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.

Michelle Cooke, MD: 2:01

So starting my DPC certainly was scary, right? And it's okay to have fear, but I think what's more scary than starting A DPC is imagining a world without DPC. And I think we're at that point in healthcare where if we don't jump to it as doctors and start to rescue ourselves and rescue our patients, we don't wanna see what that world looks like. So that's much scarier than starting your DPC. I'm Dr. Michelle Cooke of Sol Direct Primary Care, and this is my DPC story.

Maryal Concepcion, MD: 2:39

Dr. Michelle Cooke is a board certified family physician and founder of Sol Direct Primary Care in East Point, Georgia, a practice uniquely dedicated to black women's health and wellness. Recognized as a top doctor by Atlanta Magazine and Castle Connolly, Dr. Cooke is passionate about transforming healthcare through personalized patient-centered care. A proud graduate of Spellman College and Morehouse School of Medicine. She has built her career on addressing the needs of women in the black community with a special focus on eliminating health disparities. Her expertise includes treating obesity, metabolic disease, cardiovascular health, and providing compassionate menopause care. Dr. Cooke is committed to empowering her patients to achieve optimal health through lifestyle medicine. In addition to caring for patients, Dr. Cooke is a passionate advocate for the Direct Primary Care movement, believing that physician wellness and autonomy are essential to providing high quality patient care. She firmly believes the direct care model is the optimal approach for delivering personalized, accessible care. Dr. Cooke speaks both nationally and locally about DPC. Encouraging her physician colleagues to explore this viable practice model and consider starting their own DPC practices. She has contributed as a writer for DPC News and runs her own newsletter and podcast building DPC, which helps physicians learn more about the benefits of the DPC model. Welcome to the podcast, Dr. Cook.

Michelle Cooke, MD: 3:59

Thank you for having me, Marielle. I've been waiting for this. My DPC story has been so big. And my journey to DPC I remember listening and imagining one day I'm gonna have my own DPC story. So this is like a dream come true.

Maryal Concepcion, MD: 4:12

Well, I'm so glad, and it was never a doubt in my mind. I remember when I met you for the very first time with your son and your husband at Dr. Krista Springsteen's reopen house, and it was so fantastic and I, I just loved, loved, loved what you said about how you networked and how you went about escaping your pre DPC world to go to DPC. And and you haven't listened, Dr. Cook has her podcast. building DPC, so definitely take a, listen. It's 10, 10 episodes, correct. 10 episodes and a bonus. Okay, awesome. So it's 10 episode plus a bonus where she goes into even more detail. So definitely make sure you listen to that afterwards. You can find it on Spotify, correct? On Spotify. That's correct. Correct. You can find it on Spotify, but origin stories, let's get into it. So you. We're not necessarily originally from the Georgia area, but you've been there for quite some time. You went from graduating Morehouse School of Medicine into this world of I want to do the best for my community with all of the, all of the tools and lessons that I've learned as a physician. But it didn't, you didn't stay in fee for service. So tell us about that.

Michelle Cooke, MD: 5:21

My goodness. So you're correct. I'm not originally from Georgia. I'm actually from the Greater Boston area. That's where I grew up. But I came down here at the age of 17 to come to college, Spelman College, which I'm so proud of. And that's kind of where my journey with having. I guess the best Spelman, if people don't know Spelman, it's a historically black college university. It's one of those schools and it's one of the few that's only for women. And so coming to a place that was so empowering for young women as a young black girl growing up in Boston, it was very difficult for me because I often felt like an outsider. If you're smart, there wasn't really communities for you. There was a lot of being othered growing up. There was a lot I love about growing up in the city, but there was a lot that was very hard for me. And coming to Spelman, I call it one of my top three decisions in line with marrying my husband. It's one of my top three decisions because it finally gave me a place where I could be Michelle and not the black girl in class and be myself and flower academically. So I'm very, very happy about my Spelman experience, one of the best experiences of my life. And then after I finished Spelman, I crossed the street and went to Morehouse School of Medicine. And Morehouse School of Medicine is also an a historically black college university at the graduate level. And it was a different experience from Spelman, but also a very incredible experience because, I mean, if you pay attention to the history of this country, we've had a problem with racism for a very long time. And up until today, very recent history. I say that to say a lot of the professors I worked with there had been the first black doctor to do so many things. Like the first black doctor, first black pediatric surgeon was there, when many of these doctors started, our hospital system was segregated. So they remember these stories of what it was like fighting to be a physician and to have that backing you was incredible. And their mission was always serve the underserved. We're here to serve the underserved. That's the mission of what we do at Morehouse School of Medicine. So we're, or for being a at the Morehouse culture is also very powerful for me and very important for me to carry that mission as I went forward. So after I left Morehouse, I trained at a um, at a at a residency program that's now collapsed and it's part of the reason why I'm in DPC. Called the Atlanta Medical Center. I did my, my three years of family medicine residency there in the heart of the city, very close to Morehouse School of Medicine. And when I finished there, I remember looking for my first job opportunities. And I came out of residency in 2014. And at that point, I mean, you're not, you're kind of in that range. Two Marielle, I don't think anybody was talking about private practice. Like we're watching private practices fall. They're being bothered by hospital systems. No one ever said, do private practice. You're gonna fall. You're just a doctor. You can't learn business. Let the business folks do it for you. You just need to figure out a way to practice medicine. And honestly, that sounded good to me too. I'm like, I don't wanna figure out the business. Let me just go treat the patients and do it the way I wanna do it. What was funny was when I first started looking for opportunities, I had this opportunity and it was gonna be in like one of the most expensive, one of the wealthiest neighborhoods of Atlanta. And the office was beautiful. It was interesting. It was, it seemed like it might be a good deal. I remember thinking, I was like, you're from Morehouse School of Medicine and we're here to serve the underserved, and what are you doing on one of the most expensive streets of Atlanta? So not to say that these folks out here don't need service, but I think your, your skillset is better served in another part of the community. So I dedicated my time to being in the southwest Atlanta community, which is a historically black community of Atlanta. It houses Spelman College, Morehouse School of Medicine a lot of graduates and just, it's a very historic place in Atlanta and this is where I really wanted to serve. And so I tell folks that when I got into fee for service, it was still very mission driven. I wanted to be in the community. I thought it was best to serve and I loved it. Initially, I had this small practice, they were doing this doc in the box model. There was like one doctor per practice. So I, I felt like I had a lot of autonomy initially, but the goal just became numbers, numbers, numbers, numbers, numbers. The other thing that happened is there was a shakeup and my original practice was bought out by another medical facility. It was a not-for-profit hospital. I went from a a for-profit system to a not-for-profit. Which I thought was going to be great, but as we're learning now, not for not for profit just means that on paper only, they behave very much like aggressive corporate machines that are for profit. And so I thought everything was gonna be good, but things just continually got worse and worse in terms of the requirements of what I was supposed to do. And then even worse with just how much say I had. So, like a lot of doctors who in, in fee for service, I had no control over my appointment times, 15 minutes per appointments. Sometimes 30 for some physicals, but you're often overbooked. So it ended up being 15 minute appointments. I always felt like I was drowning. And what made it feel really hard too is I don't, at the time, I felt like a lot of other doctors would complain about how frustrating their jobs were. But I don't think anybody else to my feeling really expressed how difficult it was. Like I felt heartbroken. I was like, I'm looking at people in the eye saying this. You've got nuanced diabetes and having to run out the room or you've got cancer and having to run out the room. And what that was doing to my soul was crushing me every day. So you're doing your best to show up for your patients, but you're asked to do the impossible over and over, and it just does not feel good. Then you add on top of that just the amount of administrative load, so your notes aren't done. You're staying until 8, 9, 10 o'clock to get things done. You're working all your weekends, you're trying to reply to MyChart messages. You're just trying to stay on top of this train. It just won't stop running. I used to describe it as like being in the ocean, being like knocked down by a wave and hopefully you can stand up long enough before you get hit again, but the only inevitability is you're gonna get hit again. So you better hope you get up because if you can't get up, like you're gonna be washed a destroy and just like fumbling around. And so I always felt that way. And then things just increasingly got worse and worse where again, not enough time with patients, not enough time to handle my personal my personal life couldn't show up for my son the way that I wanted to. Missed all kinds of events at school because they would tell us like three weeks in advance they're having the school play, but I'm booked out six months, so I just couldn't make that barter anymore. And it was really, really challenging. To me, what ended up being the nail in the coffin, or one of the nails in the coffin is I really tried to get into leadership. I'm still that, that person that's so hopeful I can make a change. Maybe if I get into the right circles, maybe I can help fight this and fight for doctors. But as I got into leadership and I was the regional director for my area I started to see it from the other side. I'm glad I got the experience, but it really just solidified my, my desire not to wanna stay in this type of field of medicine. But in leadership, the language I was hearing about doctors was, it was quite, quite frankly, it was disgusting to me. It was, they don't wanna work to their capacity. All they wanna do was complain. People wanna cut off their schedules, we gotta get them working harder, working faster. All of this stuff. I was set to do all these performance improvement plans for doctors who had fallen behind on charting. And instead of really being compassionate towards this position, I feel like I was there to crack the whip and make people perform better when I tried to bring up real issues like our lab keeps closing too early, we can't get our patients to get their lab work done like that fell on deaf ears. When I tried to talk about the challenges, and you guys may hear me talk about this before, were playing inappropriate music in the office, like that fell on deaf ear. So every small problem just was unsolvable. And the bigger problems of hounding physicians became more and more real. And I just knew I didn't wanna play that anymore. So I'm rambling a bit here. But I will conclude this because we're gonna talk more in the interview. But as things got tighter and tighter and tighter and there's a pressure point coming, the biggest thing that happened was my hospital system ended up collapsing in the city of Atlanta. So in Atlanta and Southwest Atlanta specifically, it's a major hospital system. Think about a Mayo Clinic or something like that. Well, not quite that level, but everybody has these like big, local hospital systems and they have multiple hospitals, multiple clinics, and they shut down in our region. They never had said a hundred percent why they closed. But you know, we hear people talk about like low reimbursement rates, poor payer mixes, patients not being able to pay enough, our ER being overutilized or losing all this money on uncompensated care. So even though we had so much care to deliver, the model wasn't making sense and it caused us to collapse. What made me, what broke my heart was that it collapsed in, my community in the, the black community of Atlanta. That was one of the most underserved communities of Atlanta. This whole system is gonna stand, but we're getting left behind. And so that was a wake up call to me that this is not working. I don't wanna plan anymore. I fought as hard as I can to make it work, and it just wasn't going anywhere. So, after that, they, they terminated all of our positions, not for like any, any quality issues, but just saying, we're gonna shut down this community, come with us back to that fancy side of town that I originally declined. And I decided, nope, now it's the time for DPC. I had been kind of looking at the movement for a while, and when that happened, I knew I had to take the leap.

Maryal Concepcion, MD: 13:47

So I think about, the, the. Richer part of the neighborhood is probably going to also have different codes compared to, where you guys were practicing and taking care of your community, which is disgusting and of itself. But I wanna ask about this time where you tried to go into leadership, many of us who eventually do DPC take that route. Right. And I would love, you, you mentioned how you saw, from the inside of the beast, what physicians were viewed as we, all of these, we are complainers, we're the people who just need to work harder. We need to just shut up and be coders. Right. Basically, is what I take from that, which is unfortunately very true in a lot of corporate situations. I'm, I'm wondering if you as you talk about your practice and as you talk about your desire to serve the community, specifically the black community, especially where you were, where you were geographically located. Mm-hmm. I'm just wondering about, did you. Take that idea, take that hat of I want to be a leader and try to morph it into something else. As your hospital system was closing, did you look at other ways to be administratively involved in policy or, things in your neighborhood? To, to, yes. Be a doctor as part of Dr. Cook's training and abilities, but also to speak for the greater community of physicians in your area. Because I think, especially when you talk about that your hospital system closed, I, it just, it makes me, and I'm sure it makes many of the listeners just very, very upset and frustrated because especially people like you and I who go into family medicine, right? Community, community driven work is at the core of what we do. And so I'm just wondering if there was a part of you that said what else can I do in addition to becoming, my own physician in my own clinic. What else can I do for the greater community of physicians around me?

Michelle Cooke, MD: 16:33

It's excellent question. So I think there's a couple ways to answer that. And I'm, I'm hesitating because as that transition point was coming, I feel like I was in a very dark head space myself, so I think the spirit that you see right now of I wanna be a fighter and I wanna make sure that all physicians have options. It was still there, but it was, it was really questioning whether I even really wanted to stay in medicine. Everything I saw was like, you wondered, is this really worth it? Is this really, I worked so hard for personally, I'd just taken so many hits, like giving so much of myself to my job, having my family suffer. It was really a strain on my marriage in a way I never expected it to be. So as much as I wanted to keep advocating, I realized that as I was leaving the system, I needed to heal. Like the burnout was astronomical. And I didn't realize how bad the burnout was until you get out of it. You don't realize how bad, like the fire it is until you, until you can cool down and say, oh my gosh, it really was hot in there. And so I say that to say at first I think I was just thinking about survival and how I was going to continue to do something to earn income that wasn't going to make me feel like a crazy person or, or, or burn me out so much. And advocacy was second, like that fire was still there, but I, I was really questioning whether I wanted to keep fueling that fire because it burned me so badly before. But when I talk about other efforts, I would say the other efforts is just continuing to network with physicians locally. You may know that when I learned about DPC and I was going into this pathway, I wanted to make sure other physicians knew about it.'cause a lot of people didn't. So, even very early into my DPC journey, we did a DPC mixer here in Atlanta that now we've done annually. It was odd to do that because like I was barely even in DPC myself and I'm like, look, guys, come together. There's a secret and we need to tell other positions about what's going on. Christa Springs was there, Anand was there. Anon meta people who I listened to their DPC stories. So building community was very important. I wanted to do it in a very organic way. Not when it had to be super formal or super professional, or not necessarily even connected to any medical society, but just building community. The second thing I did is I did wanna try to keep up my skills. And I remember doing some volunteer work with Morris House School of Medicine, which I still do quite a bit of working with medical students. They have a student led clinic that I go to volunteer at, still continuing to give care largely the people that don't have insurance or who are underserved by their insurance. And being there has been a way I've been able to continue serving my community. One funny thing about working at that student clinic is I, I tried to do some work there when I was still in fee for service, but I was so overwhelmed I couldn't give my time. And I remember working with a medical student one day and, we were talking about a patient and talking about, just the case and everything and, and she's med school is so, so hard. And she looked at me, she's it gets better after you get out, right? And I remember staring at her and that was a really critical moment for me. I remember thinking, I can't lie to this poor girl. I was like, but I'm absolutely miserable what I do outside of here. Like being in this clinic and working with patients who are appreciative to be here, that value our opinion, that we have some autonomy of the flow is like the best part of my week. And it just, it was a wake up call to me that so many things are wrong. And so as I moved into this, like my, my giving back has just been trying to do more advocacy and making sure the word is out there, not only for other physicians, but for patients, for medical students, letting'em know that there's another way. So that's a weird way to answer the question, but it's, it was definitely marred by the fact that in, in coming out, I was still dealing with a lot of my own burnout.

Maryal Concepcion, MD: 19:50

And I'm so grateful that you shared that also, because there are so many listeners out there who are in the throes of, but. I'm supposed to do this. This is my job. I'm supposed to show up for the patients. I I just have to make it work. And that's very real. What you described, the, the burnout was astronomical. The burnout was such that you couldn't even realize what it feels to not be burned out Right. Until you were not burned out anymore. And so I, I hope that that is eyeopening for a lot of people. When you talk about the talking to the medical student, I remember the very first time that we met, you mentioned that to me. And, ever since then, I've literally looked at when, when residents are getting awards and whatnot and they're going into their first year residency. It's really messed up. But in my mind I'm like, why does this feel like the Hunger Games unless we prepare people? Yeah. And it's terrible, but it's like literally this is how Muriel's mind thinks.'cause I'm like, if you do not prepare people for the options that are out there, you are not doing anything. But literally sending people to the wolves. Right. So on that note, when you started networking with your community and, telling other people, I just laugh because people like Dr. Depo Baa, who's been on the podcast, was your attending and she learned about DVC talking to you and other people. And then you have other people who you trained with who are also doing DPC or planning to do DPC, which is fantastic. But I wanna ask about when you went from this, Dr. Cook, who is, who, who was doing the fee for service thing, wanting to just, take care of yourself in, in enable in order to be able to flourish going forward, how did you go from that person, that burned out person, getting out of that model to. I have a different mindset.'cause mindset is a big word that I, I love when you talk about, but I, I'm wondering if you can share with the listeners how your mindset's shifted because you could have very much not gone into medicine like you were thinking about but you stayed in,

Michelle Cooke, MD: 21:56

right. Wow. And, and mindset. It's funny'cause I think people kind of think of like mindset work as like the woo woo work. Like it's kind of hippie dippy and doesn't make a lot of sense, but it's so powerful. It is so powerful. And none of this happened overnight. In fact, I would say a lot of it started when I was still in fee for service. And I would say the first thing that really got me working on mindset changes was working with my own therapist and I still see a therapist. I actually started doing therapy more intently when the pandemic hit. If we guys can remember back to that march April timeframe when the shutdown was happening. It was funny because like things shut down enough for me to say I haven't mean to do therapy for a while. Lemme actually look somebody up. Like I've been putting it off. But finally I had a little window to take care of it. I remember working with my therapist and talking about the work stresses that was going on, and I remember her saying something to me, or I said something like, there's no way to be a good physician and still keep your heart about you. In order to do this, like you have to become hardened. Like you have to stop caring about people. Like you can't be a good physician and be a good person. And I remember her saying, well, that's a thought, like that's a mindset issue. That is a, a, a limiting belief that you have. And I think there's ways around it. And I thought she was absolutely insane. I was like, you have no clue what it's like on this side. There's no way you can like practice this kind of medicine 15 minute, 15 minute like, and short people all day and be like a good person anymore. Like I just didn't believe that there was a way around this. There was a way to practice medicine and do it holistically. And I remember just thinking she was absolutely insane. And at that point, DPC wasn't even on my mind, but I remember that thought of like, how does she think that you can practice medicine and not have it be soul crushing or not become like a hardened person or not? Have it just affect your soul. But as I started to introduce the idea of what if, a lot of people say what if you don't even have to believe it yet. But just what if you could imagine a different reality? What if you could think about this differently? If you weren't afraid to fail, what would you do differently? And I think if you can give yourself permission to just even explore the possibility so much more becomes available for you. And so I started playing with those ideas of what if, or how can you do this differently? And then listening to people who've done it differently, which is why my DPC story is so powerful because you hear other people who are in the same boat that you were in find ways to do it differently. So a couple of things I've helped. One, I started focusing on my own self-care a lot more. Sometimes even at the detriment of my practice, like my practice of as being in fee for service at the time, doing a lot more yoga. I invested in like doing more running. I, I never thought I'd be a runner, but again, just given myself that thought, what, what You did run a 5K run. We did run a 10 K and like training towards that and giving my brain something else to focus on that wasn't medicine just allowed me to understand that I had this plasticity of my brain that if I wanted to apply it to different things, I can do that. And that becomes intoxicating because I think at one point everything was like patient's notes, patient's notes, a little bit of sleep, patient's notes. Like you, you were in this site, this hamster wheel, you can't get off of it. You didn't even have room to explore other things that might be interesting, but giving up space for what if was really, really powerful for me. And so it went down this rabbit hole of like listening to more podcasts and my DPC story was up there. Dr. Una is one I highly recommend. Meditative story. I dunno if you've heard of that one, but it's like people doing interesting things. There's this other great podcast called wild Ideas about people that do things in the nature space and take wild ideas and commit to them. So hearing these other stories of people that just take these wild leaves, let me know this. You're not so different. Like you may feel like your life can't be different, but you're not so different. I can challenge my body to do things I never thought I could do. I can challenge my mind to do things I never thought I could do. And so the more I was able to open my mind about different things, like that's where the mindset shift started happening. And really asking myself the things that I believe so strongly are they really true? And again, it sounds very fruitful, but is it true or can you substitute a different thought and can you think about this differently? So years of that type of mindset work has gotten me to a place where I still have more mindset work to do. But I think allowing yourself to believe that there can be a different way for things to be done holding fast to things that you think are so true. Can be more detrimental. I was actually listening to an a podcast last night by Dr. Benjamin Hardy, who wrote the book 10 X is Easier Than Two X. And he quotes Mark Quain saying it ain't what you don't know that will hurt you. It's what you know for sure. That just ain't so. And that's so powerful.'cause there's things, I think we believe in medicine, like there's no way you could be a good doctor, and do medicine. Or there's no way that you could leave fee fee for service and not, rip people off. There's no way that you could, like these, we have all these things that we're so fixed in our beliefs about, but they just think so, and, and that's really what's gonna hold us back. So I think just being willing to think differently.

Maryal Concepcion, MD: 26:32

And I think that even just zooming out into the entrepreneur space, you have. All of the baggage, all of the experiences to take with you into how to do it differently, how to do it better. And when you're able to have that freedom and the time to be an entrepreneur as well as a physician, you can picture doing different things. And I'm so excited because we're gonna talk about how your practice sole DPC, has blossomed from, one, one doctor to one doctor with multiple staff and multiple things that you're bringing to the your community. So let's talk about. Your practice, you go to your website. I mean, and I'm just gonna cheat really fast here'cause I have it up and then I'm like, I don't wanna mess it up. You, you go to your website and it literally above the fold says the sacred space for Black Women's Health and Wellness. And given what you already shared, I'm flipping in love with your website already. Like I, I just need an, I just need to note that, but also the fact that you have really honed in on a practice really centered around your mission that you went, to medical school for, and you, discovered along your journey at Spelman and at Morehouse. So tell us about centering a direct primary care c your direct primary care clinic around the health and well and health and wellness of black women in particular.

Michelle Cooke, MD: 27:50

Absolutely. I love that question. And that was a journey because when I came into this, I've always known like who I think I can best serve. I've always known that in the back of my mind. I think when you go into especially a field like family medicines, like we do everything right? There's nothing that we can't touch. It's hyper inclusive, which I think is great because I think what's great about family medicine is that we can do that URI potent stem cell, like we can turn into anything, right? But I think sometimes in family medicine we feel like we have to take care of everything and everybody. And if we're not doing that, then we're not really fulfilling the heart of family medicine. And so when I was in fee for service, every patient that we can touch was a potential patient. So a lot of patients were attracted to me because I was a black woman. I think a lot of people wanna see themselves in their doctor, but you know, anybody and anybody could come and I'd be happy to take care of all those people. But when I'm really thinking about in the back of my head, who I think I can best serve, it is women. I know that, that have my story that come from where I've come from, who have felt discrimination in medicine, the way that I felt discrimination. Like I feel like I can serve that community uniquely. And DPC finally gave me for the permission to do so. And it's especially interest in this conversation about what's going on with DEI in this country. And it's very controversial and I'm kind of leaning into that controversy. DEI work has been very important to me, but I've also been a little skeptical of it. I do think that we need to embrace diversity, but forcing people to embrace diversity that don't wanna embrace diversity, those aren't the people I want in my circle. So I kind of feel like I'm putting my flag in the ground of this is what I stand for and if you love it, support me. And if you don't get outta my way, like I just, just don't stop me. Like just get outta the way. Which is a very controversial thing to say that I don't think Michelle if five years ago would've ever said that, but it's like there are people out there who feel unheard and you need to call to them and you need to create a safe and sacred space. And for so long I was so afraid to do that.'cause is this racist? Are people gonna say, this is reverse racism? No, I'm calling out to the community that really needs my support. Doesn't mean I won't see anybody else. Absolutely not. If you want my support, I'm here for you. But we are mission driven and what helped this again was the, the beauty of DPC, you could never say this if you were in a big network,'cause of all the legal and we're gonna, upset somebody. This is anti DEI for DEI, we don't know. But it gets messy in those spaces. But when you have a small private practice, you can stand for what you stand for and nobody can stop you from doing that. The other thing that helped me understand that was the beauty of marketing. I never knew a thing about which, what I thought I knew about marketing just wasn't so right. So what I thought I understood about marketing I've learned so much being in the DPC space and what I've learned, particularly for small business owners, like having a niche is so important. It's like you can't compete on a big scale. I can't compete with a Mayo system or a Cleveland Clinic. Like we can't be going after the same pot. But if I can say this is what I do so well that nobody else can do this, like Cleveland Clinic and I'm just using them just'cause they're big terms, hopefully that's not. Like off limits here with my DPC story, but like the big healthcare system can't get that niche because they just, they just can't. And so that ends up being your superpower. And I love seeing that with DPCs across the country. So there's a doc, Dr. Anna Myra, she's in in Minnesota or wi I'm gonna mess it up, but she's in the Midwest. Lemme just say that. And she's neurodivergent and her whole practice is based on neurodivergent. She was like, I think very differently. I hate going to places where the lights are too bright, the sounds are too loud and my practice is gonna be perfect for the neurodivergent person. That's incredible. So I love how DPC allows what doctors do best to really flourish. And I think that's how we're gonna best serve the community, not by making us these like robots that have to take care of everything the same way.'cause we're just not that way. I think if you can allow doctors to really bring forth what makes them special and bring the patients to them that need that specialty, we're gonna best serve our communities. So going from kind of like a generic, Hey, this is sole direct primary care. Anybody come to say we are The sacred space for black women's health and wellness has really helped my practice explode because finally women are saying, oh my gosh, I've been looking for you for so long. I felt so unseen. I didn't know if I was safe here. I didn't know if I was gonna be okay walking into the spaces of black woman, and I know that coming here, I'm gonna be okay. So it was, it was one of the most powerful things I did. It's one of the most controversial things I did. But again, leaning into that controversy, so stand with me or just, just don't, just don't get in my way.

Maryal Concepcion, MD: 32:53

And I think it's sad that to anybody, it would be controversial because it's your practice. You do with it what you want. And I think that it absolutely speaks to why we have big box stores to shop at, but in, in this time, a lot of people are purposefully finding other ways to get things. It might be a little bit more pricey, but get things to their door to support, to support small business owners. I know that intentionally I'm doing things like fantasy Island Toys is a mom and pop store in Fairview Alabama. And she, the, the owner is a good friend of mine, and I'm like, that's where I'm gonna order my Easter baskets from in the future. And it's little things like this where. The I think that as a country we are seeing people want personalized care and you are doing just that. And for those who think it's controversial, absolutely you're entitled to your opinion. But I am so excited that you have discovered, this, this is your marketing jam and this is your community and how to speak that you're already doing that to the community of patients you want to see in your practice. So tell us though, we're doing this interview at such a time when when diversity and equity and inclusion is something that ruffles a lot of feathers. Mm-hmm. And as a person whose parents, my dad immigrated here and didn't even speak English when he came in the sixties and he, he. He showed me a way of when you work hard, you can do different things. Like you can do lots of things. And it's just heartbreaking to think about the services that went away when your hospital system closed and when it comes to having personalized care. You, you spoke to it exactly. You, it really helps to have somebody who looks and experiences life similar to you. So tell us about serving the black woman in particular. What is the health access like, in the greater Atlanta area, especially in Southwestern is Southwestern, right? Southwestern. Mm-hmm. Southwestern Atlanta. And especially in southwestern Atlanta. And how has that changed because of sole direct primary care being in existence?

Michelle Cooke, MD: 34:52

It's, the landscape is horrible. I mean, that's, even before the hospital system closed, we were already like a healthcare desert. We didn't have enough services. We were very un, un underserved, unmet need area. And the hospitals are really a lifeline. And across the nation, we know that black women suffer disproportionate mortality, especially when it comes to maternal health. Or obstetric health, like we die at much higher rates. Even that's seen in, in developed world, like it's pretty, pretty awful and pretty abysmal. With the closure of those two hospitals, we actually lost two maternity wards in this community. So we're traveling much further to have our babies and oftentimes getting substandard care. So, I'm networked with a lot of the black female physicians in this community, and almost all of them have horrible birth stories. We're talking about physicians here. We're not talking about people who don't have access to s and they don't have, don't have some type of access. These people have all the access and they're still getting substandard care. Now, I don't do obstetric care anymore, but life caring for the whole woman matters. The more she gets prepared for pregnancy, like the better her pregnancy will be. Like even if, there's factors we can't control, the healthier she is, I feel like I can help that moving forward. All of that to say, I mean, we had so little before, and those two hospitals were big anchor points for us. And with those hospitals collapsing, it took tons of care with it. If you think about the clinics that feed the, those op, those hospitals, they suffered greatly. Like the OB offices are nearby. We had a, a really amazing orthopedic office that operate at those two practices that shut down because they had no place to operate anymore. So the care has been abysmal. We're starting to see other places pop up, so there's actually two new practices by black women in the area that are opening, which I'm now just so thrilled for. At one point I might see, oh my gosh, this is competition, but I'm like, no, we're so far behind the eight ball that we need everybody here trying to start these practices to help move the ball forward. But the, the landscape has been terrible. And people are traveling so much further to get good care. Some people just aren't getting care. I do a lot of community events, I do I was just at the hair show, black women, we love our hair. So we set up a booth at the hair show to tell people about Soul Direct Primary Care. And I can't tell you how many women stop by. It's oh my gosh, I haven't seen a doctor for four years. I haven't had a pap smear for five years. I haven't, had my blood pressure checked. Oh my gosh, can we get an appointment with you? Like people are just neglecting their care. So we're, I'm, I'm devastated at what's happened. I always say, I don't think we're gonna solve this problem in my lifetime, but we gotta get a head start. We gotta get on it now. And that's exactly what my practice is doing.

Maryal Concepcion, MD: 37:16

I love it. So you opened in May of 2023 and you've already gone above and beyond 230 patients, which is incredible by the time of this interview. And so I'm wondering in terms of scaling as you. As you not only went from physician to physician, entrepreneur, you've scaled pretty quickly. So my question would be what are your top tips for those people who are wanting to scale, but also wanting to remain intentional about their practice and personalized care as they're scaling in terms of sheer numbers of members of the practice?

Michelle Cooke, MD: 37:52

Absolutely. Well, I will say that I had a huge headstart in that I had been a physician in the community for a long time. So my name was pretty well known. Even when I was in fee for service, there were a lot of people like, oh my gosh, I wanna see Dr. Cook, but I can't get under a schedule. It's a six month, one year wait. So it did help to be of the community. So I think if you, if there's a place you know, you wanna be like, get your name known there, stay there and try to sit up there as close as possible. Another great thing, or great if you will, is because the hospital system where I was at effectively closed in the area. It did release me from my non-compete. I had to do a lot of legal finagling and pay a lot of money to figure that out. I was able to set up shop pretty close to where I was practicing originally. So staying in that same community made a big difference for me. So when I opened the practice, I had about 60 people that pre-registered that got me started. So I got a really great headstart. That being said, there is churn in direct primary care. People come in, they're like, oh, this is exciting, this is great. And then, they fall on hard times or something happens and, and they fall off. And so I think the way that you can start to grow and scale, number one, I think the most important thing I did was create that patient avatar and really niche down the practice and become mission-driven for doctors who are coming from fee for service. I think it's hard to imagine that patients won't be beating down your door once you open it. When you're in fee for service, like there's so many patients you don't know what to do. There's all these you are overwhelmed with patients. And I think you get this mindset of if I'm a doctor, people will come. And that is just not the truth. I think I'm a darn good doctor, but I still don't have the numbers that I want yet. Right. And it's been very hard to get people to come through the door, but I say that because. DPC, especially with most small businesses, it's not just a numbers games, it's a match game, right? You wanna get the people who not only wanna be in your practice, but wanna be committed to your practice. And so you're gonna get a lot of nos before you get yeses, but when you really define who you're looking for, and for me, we're looking for a very specific patient. Now, other people that believe in us, we want them too, right? But when I'm looking for that very specific patient, when she commits to my practice, I know she's committing. She was like, I don't wanna go without Dr. Cook's care because this is so important to me. So I'm not worried about that person leaving, as opposed to the person that's oh my gosh, I'm in distress. I woke up with strep throat. The urgent care is packed. Like you're my only deal in town now. Yes, we'll help that person too, but you're less like, that person's less likely to be committed to you. Direct primary care is an ongoing relationship. You wanna make it a good match. You're kind of getting married to these people and you wanna make that commitment going forward. So I think the more specific you can be about who you're calling out to, the better. And sometimes reaching out to everybody kind of works against you because if you're not unique or your practice isn't special, or have a special meaning in someone's heart, they're gonna drop you. The minute they get like insurance oh, I was uninsured and now I have insurance, I'm gonna leave your practice. Or, there's someplace a little bit closer, so I'm gonna go to that place. You want it to mean something to people. But there's no place else in Atlanta that says they're the, the, the sacred space for black women's health and wellness. So you can leave if you want to, right? But you're not gonna find this level of care anyplace else you go. So I think really making your practice mission driven, defining who you're looking for makes a huge difference. And then telling the story, whenever I get a chance to talk about DPC, I talk about DPC. And when you're starting your practice, you feel this pressure like fill quickly. So you, you feel like you're trying to drive the deal a million times. Oh my gosh join my practice, join my practice. I had to let go of the pressure of that get used to people saying no, not wanting, getting on board, but really just making sure they understand what your model is about, hearing it time and time again. So again, I've learned a lot about marketing. I've learned that people need to see something at least seven times before they make a commitment. So you have to make seven touchpoint, right? So that first touch point, expect them to say no. That second touch point, expect them to say no. Third touch point, expect them to say no. You've gotta keep telling the story. And the more you can get other people to tell the story, that's gonna be another touch point. So, for instance, if I meet somebody at a health fair and they're like, oh, so, oh, this is a non-insurance based practice. That's weird. I don't wanna hear about it. But then, their friend is a member and they go back and they say, oh, I saw Dr. Cook at, so Oh, you mean that non-insurance based practice. Oh, that's cool. You kind of get the buzz going because people hear about it more and more and more. So I talk about it every chance I get. When I'm invited to do podcasts, I do it community events where I think my, my ideal patient's gonna be there, I'm gonna be there. Opportunities to speak, like you've gotta keep pushing for your practice, but also for the movement. I want people to join my practice, but if they don't join me and they join Dr. Baby and Marietta or they join Dr. Meta who's in Marietta, or they join Dr. Springsteen and, and Peachtree City because they believe A DPC, that's a win for all of us. And each of those people that tell the story is gonna make it easier and easier. So touch points matter. Like I said going to community events, word of mouth, encouraging my patients to leave reviews so that people go to the website, they hear other people talking about it. And even though it can be a real, I'm not gonna say a pain, but it can be work to do it. I think a newsletter is very, very powerful. So I have a lot of people, I, I have 247 members as of as of yesterday. But I have over a thousand people on my mailing list. And so those patients are hearing about DPC all the time and sometimes they're not ready to join, but if we do an event, they show up, or if we have a special offer we're doing, we're did, we did a, a research project where we did free blood draws. They showed up. So even though they're not here yet, they're lurking. Right? Get them in your circle. I think. Dr. Oh, what's his name? Phil Boucher talks about people having people in your orbit, get them in your orbit'cause they're watching and then one day they may actually convert and become a member.

Maryal Concepcion, MD: 43:17

Love it. Now you went from being a solo doctor, no staff, to a totally different space. It's absolutely gorgeous. Make sure you go to soul dpc.org and watch Dr. Cook's video. It's beautiful. But tell us, because since you've opened, you've added both Toya and Brie to your practice. Mm-hmm. And I'm wondering if you have any best tips on hiring people, especially finding the right people who are, going to be quote unquote married to your practice as much as your patients are.

Michelle Cooke, MD: 43:46

Yeah, this is a fun story. So, I started with a virtual assistant who's still with me. Joy is my heart and soul. Like she's my ride or die. I love joy. So starting with her has been so good. And I would say sometimes with DPC we get this mindset of do it yourself. It's all DIY, it's all DIY. The more you get better at being able to delegate, the more you're gonna be able to do. Like, As a doctor, you do wanna do most of the doctoring and not all the other administrative stuff. That's how you're gonna serve more patients is if you have help to do the other things. So I came on, I had a virtual assistant, which was a very big learning curve, like learning how to train somebody who's remote, how do you have, all those touch points to, to make sure they do what they're doing, what they're supposed to, how do you evaluate that they're doing what they're supposed to do. It's a very different skillset. So picking the right person matter. When I interviewed my va, a lot of the companies will have you interview different people, and I really paid attention, not so much to how she answered questions that I asked, but how she asked questions back to me and my VA stood out because I remember her saying things like, well, if you're not using insurance, like, how do you send referrals? Or what happens with medication? I was like, that's why I want, because she's thinking my patients, like all the questions my patients are gonna ask, like she's already thinking like them and she's gonna be able to assist them because she's, she's understanding what that gap is going to be and it's been a perfect fit. So starting with a VA was so, so critical. And then when I started my practice, I was subleasing from another doctor. So I had a room in the office, like an office space, and I had an exam room. So I had two rooms in that place that I controlled and I did everything. So I was doing vital signs, I was doing check-in, checkout, like all the stuff on the floor I was doing, which is a lot of fun. It can be exhausting. Now granted, when you're only seeing a couple patients a day, three, four patients a day, it's doable. But if you do wanna get to the point where you're seeing 7, 8, 9 patients, it's just not doable anymore. So as the practice grew, I knew we needed more space and so we found a space that was larger. I'm in a, about a 1700 square foot building right now, and I just couldn't be in here by myself. I feel like there kind of needs to be other folks. And so my bridge to getting staff is when I moved here, I moved in May of 24, so May of 23. I started May of 24, I moved to my new space, perfect time because college students were now available. So I created an internship, to have somebody on board. And yes, it was a good experience for the students, but I really needed some cheap labor and I needed people who were, who were ready to go, who were motivated. So that was a great move and it also kind of helped me get used to what it was gonna be like to train somebody on site. So I got students and who helped me for the summer. They were phenomenal. They are so passionate, they wanna please you. They were excited to get this opportunity. So work with students, work with interns if you can. They can be a great value add to the practice. But then when I was looking for who I wanted in the practice I wanted an office manager. One because I wanted additional help with the admin. And as Marielle and people who, who know me well, I do a lot more beyond what happens behind these walls. We're always doing advocacy, we're doing events, we're doing, we're just doing all the things. We're always out in the community. So I wanted somebody that would really help broker some of those community relationships and things that happen outside the practice as well as inside the practice. When I started to look at what it would cost to bring on like an office manager, I was like, oh, I dunno if I can really afford that, right? This is pretty expensive. People that have experience in the medical space that might be hard to bring on. And so I started to think about what is the skillset I'm looking for? Like maybe I don't wanna hire on position, I wanna hire on skillset. So what I did is I went to LinkedIn and I got one of those recruiter accounts. So I upgraded my account to LinkedIn and I just started lurking. I didn't really post a position and one of the reasons I didn't post is'cause I was hearing other doctors say they post on LinkedIn, they post on Indeed and they get a ton of responses, but there's a lot of garbage in there and you have to sort through a lot. I didn't wanna sort through, I wanted to kind of like laser in on who I thought might be good and just make an offer to them. So I was browsing different things and I realized that the skillset that I really wanted was somebody who was an executive assistant. You know, You support an executive, you do all the things, like you kind of have to know how to do a lot of different skill sets, stay organized. And I was like, I think I can take an executive assistant and make them an office manager, right? And so that's what I looked for. I started browsing for executive assistants, people who are in the area, and I started kind of cold contacting them. I was like, you don't know me. I'm this doctor that has this crazy idea that we're gonna change medicine. I have this, growing practice. What do you think? And I got about four or five people to do an interview with me. And Brie, who's now my office manager, stood out immensely. She was ready to take a leap. She loved her job as an ea, but felt like she wasn't really growing, wanted a new opportunity, and she was a wedding planner. So I was like, girl, you know how to do events and that's what we do here at, so, so I need you on board. And again, one of the best decisions, she's been so dedicated. I was able to get her, I pay her a very competitive rate, a lot more than I ever thought I would pay, but a lot less than what someone who comes with work experience. And what I love is that she's being grown from, from the inside, right? It's nice to bring in some outside blood'cause they bring new perspectives, but sometimes they're not willing to think differently, which is what we have to do here at seo. Look at things differently. I don't think we do. I think a lot we do in medicine is wrong, right? The way we treat patients and rescheduling and grace periods and a lot of it's not right. And bringing somebody with fresh eyes has made all the difference. And then after Brie, I brought on Toya, who is our medical assistant. Quite frankly, because I wanted to offload those medical assistant duties, I wanna do more of the doctor stuff, taking the vital signs, I can do it, drawing the blood, I can do it, but if I can get help, I can be a lot faster and I can serve more patients. So same thing with Toya. I went through, I kind of looked at different people. Medical assistants, while they're not super expensive, they are in higher demand, and so they were, they were a lot more expensive to hire. Toya is actually a phlebotomist. She has phlebotomy training, which again, I look, looked for skillset like the one thing I really would love to offload is drawing blood. So I'd look for a phlebotomist. She does not have a medical assistant certification, but if I could train a, a college student to be my medical assistant, then I could definitely train a phlebotomist. And she had some experience with that. She worked at some offices where she did some EKGs and vital signs. I'm like, that's the skillset. I don't really need a title. I need a skillset. And I needed someone who's willing to learn. So Toya, same thing. She came in, she was excited, her son goes to school like a mile from the practice. She's this is like a match made in heaven. So I got people who really weren't invested in the mission, willing to learn and had a skillset that we could work with. And that's how I, how I kind of built up my team in a more non-traditional way. And if I had to go at it again, I'd probably use the same technique, go and kind of lurk on LinkedIn and see, see who might work out. And then try to try to pull them into the, the spears full, sole, direct primary care.

Maryal Concepcion, MD: 50:10

I love it. Now I wanna shift the conversation to tech because this is something that, we are at a time where my DPC story has released the Battle of the EHRs. If you have not participated yet, just know it is a way for you to anonymously participate in a survey to say, what EHR do you use? What do you love? What do you want to see improved? And it's a way for us to present to the EHR community out there. This is what as a community DBC doctors are looking for. So please go to my dbc story.com, click on Battle of the EHRs and vote and put in your, put in your input. But for you, one of the things, one of the reasons why I wanted to bring you onto the podcast, especially in the month of June when we're doing this survey, is that you are a person who's switched between different EHRs. And I think that that's something that, when people are on the Facebook groups, when people are networking events, they're asking about like, how did you choose an EHR? How did you choose an EHR? And you've chosen not only once, but more than one time. And so I'm wondering in terms of your, Dr. Cook who was starting out with an EHR and Dr. Cook who has changed EHRs is there a difference in how you looked at EHRs similar to how you would not redo how you're selecting your team? What would you say was your mindset when you selected your first hr? And would you, and was that similar to how you chose your second?

Michelle Cooke, MD: 51:34

Absolutely. So. This is such a good topic and thank you for doing Battle of the EHR. So after we get off of this this interview, I'm going to go and do my vote because I have a lot to say about this, but you're correct. I switched three different times and what I see from my peers in DPC, a lot of us are coming, most of us are using Epic, right? And they're robust, like it's annoying, but they do everything right. And so I think we come into it thinking if you pick an EHR, it's probably gonna do that. And so you just wanna get the cheapest one. So a lot of it's like cost, cost, cost. What's the cheapest? What's the cheapest? And I think that's the first fatal flaw is that we're looking at cheap and not always looking at functionality. We're moving in a much more tech forward world. And I'm not a tech person. Like I, I try not to say these things like what I'm not, but I'm not, I don't lean into tech, but I understand that's where we're going and if we can leverage it, we can do so well. Especially with small practices touching a lot of people. Tech can help make us much more efficient. So we shouldn't always be looking at what's the cheapest. We have to look at what's going to give us what we need and what's gonna make us efficient. So I went with an initial EHR that looked like it had all the bells and whistles and things that, that were gonna make me efficient. It had this all in one type stuff and I was really excited about it. The challenge with my first EHR is that they were launching when I was launching, so they were doing a big. Launch or like merger as I came on board. And so everything was super, super glitchy and I kept calling tech for help and nothing was working. I was like, I, this is unstable. I can't stand on this. So I switched to another EHR that was very popular, but very, very, very basic. And it was affordable. Affordability is great, but again, affordability is not the most important thing. If it's affordable, but it's not doing what you need it to do, you're going to have problems. Am I mad that I made that switch? No, because on each transition I learned something really critical about what I needed in my tech stack. But when I got to the next EHR, there were just some critical things I didn't have that I needed. One was like a more robust patient portal. The ability for patients to be able to schedule appointments. The, the portal is probably the biggest one, but there were several other things. The way you sent prescriptions, the way you wrote notes, like there's a lot of other little things that made it not the one to work with and honestly made me less efficient. And when I started to imagine the practice growing with this tool, it was gonna hamper me. So if something is taking you five steps, that should be one or two. Like when you start to scale, those five steps really add up. Like in the beginning you do have, a lot of times you're willing to kind of deal with a little bit of inefficiency, but you have to think about the future. And so as I was getting bigger, I'm like, this is not working. Like my patients can't schedule. I'm gonna have to hire more staff just to make more appointments. That's not the way I wanted to work. And so I went back to the drawing board and again, started asking my peers and did some shadowing. But I do think it's helpful to use your EHR first or, or watch how someone else uses their EHR. Like I think if you can do that, that really helps.'cause you don't know what's not there until you start using it. A lot of them will sell you and they'll give you the demos and you're like, oh, I'm pressing buttons. And things happen. But you don't really know what the workflow is like until you go through the workflow. So if you're not gonna demo everything, I would try to like pair with a doctor and see how they use their EHR, like spend a half a day with them, they see how they flow through it and see if you could see yourself doing that. And you'll start to see some key differences. But for me having a really robust patient portal easy to do virtual communication was very important. Ease of sending prescriptions was very important. Billing was very important. The fact that that could happen seamlessly, like all those things really mattered. So, am I using the cheapest EHR? No, I'm not. And do I wish it were a little bit more affordable? Yes. When I think about what I would save and cost, like what it would cost me, and headaches just isn't worth it. And so I think a lot of DPC docs have to think about that. I do love that in the DPC space, there's more options that are available, there's more competition. So I absolutely would go ahead and do the battle of the EHRs because we need for them to get better. This is gonna be the backbone of healthcare, but EHR is so, so, so critical. Don't always go for what's cheap, go for what you need, because a lot of times you're gonna end up piecemealing things that that that aren't gonna, they're gonna cost you more in the long term in terms of your, in terms of your mental sanity.

Maryal Concepcion, MD: 57:04

I love that, and I think that that is so insightful to talk about your practice as you envision your practice, not your practice on day one, when there might not be, many patients to manage in your EHR. When you're talking about those, five extra steps adding up it. Absolutely. I completely agree. It absolutely impacts the amount of time you're spending per patient to get the job done.

Michelle Cooke, MD: 57:27

Absolutely. And I, I, I can't remember what episode, maybe episode five of building DPC, the podcast I made, I did a whole episode about EHRI talk about my journey. So go check that out if you're stuck on your EHR. It's a big decision and I, I don't like the fact that I changed EHR, but another mindset shift in, in, in the entrepreneur space is that sometimes in DPC when we're making these decisions, we feel like this is just the be all end all right? I've gotta make the right choice. In business, you can always pivot and you're gonna have to pivot. And the better you pivot, the better you you're gonna be as an entrepreneur. So while I don't wanna keep switching EHRs, I don't feel like if you're stuck someplace that you can't get outta that. So that that relationship, there's always a different way.

Maryal Concepcion, MD: 58:07

Love that. Now when it comes to one of the features that you mentioned about your EHR, and one of the things that you really lean into is the ability for a patient to self schedule as well as the patient portal. Which patient portal is a massive thing in my world also. But you have also leveraged your EHR to be able to do things at your practice specifically, take care of patients on the daily, but also you are very focused on obesity, medicine, metabolic health. And the other thing that I love is that, and I mentioned this in your bio, but you are bringing compassionate menopause care as a woman to your female patients. And so I'm wondering how you look to your EHR to support you in streamlining your workflows, but also to help you personalize these different ways that you are delivering care to your patients.

Michelle Cooke, MD: 58:58

Absolutely. Personalization and customization is it's, it's like a double edged sword for me, right? Again, I'm not necessarily a tech forward person, but you do wanna have the ability to customize, right? So what do I mean by that? And the world of the big EHRs, you can kind of create these order sets or create these things that you can do. It's okay, if I, if I have a way that my brain works and every time I see an obesity based patient or a menopause patient, I wanna order this set of labs. I wanna do these, this many handouts for them. I wanna have this type of patient education for them. Like you wanna be able to bundle that together and then be able to modify those things per patient because it's individualized care, but you don't wanna keep reinventing the wheel and having an EHR that allows you kind of like build those bundles, like work with the way that you think helps you move faster and helps you kind of have a way that to approach each patient in a way that makes sense, but then customize it for that patient. So I used to think that I like to just be able to, to be told how to do something and just do it. But I'm like, no, but I actually like to do it better this way. Do it better that way. And you can do that if you have an EHR that will lie to do that. So when I think about like my menopause care, there's stuff I don't wanna think about twice, right? Like these are my, the three biggest estrogens I use. I'm gonna save them. These are the progesterones I use, I'm gonna save them. My patients always ask this question about menopause, or here's my FAQ sheet. Like I have that all together so that when people need something, they're ready to go. I have forms that they can complete about that. So I have my menopause health questionnaire. I can send that to my patients through the portal. They complete it. So by the time they come in, I'm like, oh my gosh, your sports 14. Here are the things we have to talk about. So using that technology to even help with the patient flow is really, really powerful. So you need some customization. You have to lean into it.'cause again, I'm not the person that likes to figure out how to do those nuances, but once you figure it out, set it, forget it, and then you can adjust it if you need to, which is really nice.

Maryal Concepcion, MD: 1:00:44

I love it. And going back to serving your community and your community's needs, I'm wondering if you can talk to us about obesity, medicine, and metabolic health and menopause care, how you've, how, how that's manifesting at sole GPC, because as you talk about, there's algorithms and whatnot, there's also the actual conversation that you have to have with the patient who has these diagnoses or is concerned about these diagnoses.

Michelle Cooke, MD: 1:01:08

Yeah. So I, I'd like to answer that with just again, the freedom of DPC. We know that these conditions are so challenging to manage and it's not gonna just happen in the exam room. So I think one of the things that DPC has allowed me to do is give patients more than just what happens in the exam room. So we mentioned the fact that I have a newsletter. I often will do stories in the newsletter about obesity, about patients who've, who've had obesity challenges about my own obesity journey. You all will also know I'm very active on social media. I've had my own obesity. Story like dealing with obesity and weight gain has been a problem my whole life and I've gotten the handle of it. So I share that very openly. I talk about it on social media. What else? We do events in the practice. Just this weekend we did a yoga event, so managing stress. We know that people are not managing their stress. Their cortisol's up, they're not sleeping well. They're going to eat a lot more. So. What I do in the office is supported by some of the other activities that I just was not gonna be able to do when I was in fee for service. I was just too burned out. I'm not gonna be gonna social media talking about things because it's too much work and or, I'm gonna get fired because I'm gonna violate the policy of my institution. I'm not gonna put on a yoga event.'cause maybe I'm gonna have to go through all these different channels. Like I can hit people in different ways. I'm sure a lot of us hate the fact when patients come in, they're like, oh my gosh, I saw on TikTok that if you take, green tea vitamins, that you're gonna lose 20 pounds in two weeks. You're like, oh my gosh. There's so much crazy information on TikTok. But now my patients come in I saw this thing you did on TikTok, Dr. Cook, right? Like they're seeing their doctor on TikTok and they're like, oh, I'm actually getting some valid information. I'm hitting them in different ways that help support their care. And that's the flexibility of DPC. That doesn't all have to happen in the exam room. Like it can happen from some of these other channels that you do. Are kind of a part of the membership, right? Like some of that stuff is free for the public as well, but it helps me reach my members in really unique ways that I think has sometimes been more impactful than what I'm able to do in the, in the exam room.

Maryal Concepcion, MD: 1:02:59

I love that. And when it comes to the impact of the exam room, I also think about the impact that your patients take with them and they tell other people about, and I'm sure like, and this is how DPC grows with that personalized care because your patients are interpreting what you're doing in their own way and they're share sharing that with their friends and neighbors. So it's, it's, it's like a multi-fold wave of effect that you have when you just are able to be a doctor. It's amazing.

Michelle Cooke, MD: 1:03:30

Yes. And I have to add to that Maryelle, especially those of you that do obesity medicine, it is so nice to do it in the DPC space because. When it comes to especially medications, we're in this age of GLP, which I do think is wonderful. They do amazing things for people. The one place where I have to spend too much time with insurance company is prior authorization for glp, right? But when it comes to the exam space, you're kind of free. I remember in fee for service, some people would wanna come in just to talk about obesity, but then the billing department would slap you on the wrist. You can't just talk about that. We can't bill 9, 9, 2, 1, 3 or four for that. Did they have hypertension as well? Make sure to put that as the first diagnosis. And obesity, like all that nonsense is gone. Right? Maybe they wanna know, is my vitamin D playing a role here but I couldn't order vitamin T?'cause sometimes fatigue won't cover, like you're going through all these games just to reach the patient. I can put whatever diagnosis I want to order my vitamin D level now. Right? If they, if I just wanna put obesity, it doesn't matter if it matches or not because it's all cash based. So I think it's actually allowed me to o offer more comprehensive care. I can get the games out of the way. I still have to play some games with insurance companies in the realm of prior authorizations. But the care is just so much easier. I think we've made obesity care so complicated just like we've made the rest of medicine because you gotta figure out the codes first before you even get to the patient. And sometimes the coding is so ridiculous, it's not even worth spending the time with the patient.'cause if they come and they wanna talk about weight loss, that's not gonna be paid. I'm not gonna pay attention here, so I'm just gonna brush them over. But now it makes all the care equitable. Right? Your membership covers whatever you think is important to you, and I'm gonna help you through that regardless of what the codes are.

Maryal Concepcion, MD: 1:05:05

Love it. So let's talk about you, being on the side of doing the prior auths for the patients and understanding the frustrations that patients have and understanding the frustrations that a physician has in fee for service. Yeah, you have. Been able to break free from that, open your own practice, heal, continue healing, and now you're also advocating for not only your patients, but also the model of DPC, which is amazing and much needed. So definitely, I hope the listeners out there are listening to Dr. Cook's Word and getting activated because this is what we need to be able to speak for our profession and for our patients and for the way going forward with healthcare in the United States. What is at the core of what you tell every single person, whether it be the person who you meet at the grocery store or the person on the national front?

Michelle Cooke, MD: 1:05:56

Good question. I think that's a hard question to answer because I think it depends on what their perspective is. There's some people you talk to and you talk about DPC, you explain it and they get it immediately. They're like, why isn't everybody doing this? Right? And then you have some people who are gonna look really sideways and they don't understand and they just don't quite get it. Coming from fee for service, I feel like there's a lot of us that are afraid to do D-P-C-D-P-C'cause we feel like we're gonna hurt access. You hear a lot of people say, well, people need to use their insurance to access care and if I don't take their insurance, I'm limiting access. And again, I will ch I will submit to those doctors that that is a limiting belief. It's a limiting belief. And in some ways doing DPC has had made me reevaluate the healthcare system in a way that I couldn't do when I was like in the nonsense.'cause you're trying to figure out how to make things work, but when you step outside of it and watch what's going on, you're like, this is insane. And honestly, it's wrong. It's wrong. And while, do we need mechanisms to make sure people can access care? Yes, we do. Does insurance have to be that mechanism? When it comes to primary care, I can now firmly say I don't believe in it needs to be through insurance. Right? Insurance, by its definition, is supposed to cover catastrophic and unusual events. That is a total opposite of primary care. Primary care is the usual. It's the common, it's the expected, right? Everybody should get a physical once a year. Everybody's probably gonna have a URI at some point. They see their doctor for it. Everybody like everybody needs primary care. So that is not the right mechanism to use insurance to access this care. If we've all have ever had to file a claim because you had a car accident or flood insurance, like we know how frustrating that process is. And to think that we're gonna file claims for care, that's like a couple hundred dollars doesn't make any sense. You see 25 patients a day, you're making 25 claims a day. That's the bloat in healthcare. If you take those claims out, like how many more patients could you take care of and do it better by removing this very burdensome mechanism. Now in the surgical space, it might make more sense, right? Not everybody's gonna need surgery maybe once in or twice or three times in their lifetime, but that's not a usual event. It's much higher ticket. So it's probably worth it to spend half a day filing a claim to get it fi to get it paid for in primary care, not at all. Now, saying that, I think there are some mechanisms even in surgery and high, high level care that doesn't need overhaul and benefits from the direct care space. But when it comes to primary care, like we have to uncouple that. We have to uncouple because I have patients talk to me. I'm gonna use number here, Or I'll use myself. My family has a$12,000 deductible. So we're functionally uninsured if you ask me. Right? So my practice at our price point, the average adult will pay$1,800 a year. So like a fraction of what the deductible is. So when people say, I'm inaccessible because I'm not using insurance, it's simply is not true. It simply is not true. In fact, I find that more of my patients that have insurance don't access care because they're afraid of the pricing, right? They go to that visit, they have this pre-concept notion, I pay four or 500 a month in insurance. Of course it's covered. And then they get the bill for the doctor, and then they get the bill for the lab, and then they get a facility fee, and that one visit is now a thousand dollars that they weren't expecting. So I feel like what's happening in the healthcare space, the fact that we're not price transparent, the fact that meaning insur using insurance often means nothing. You and I are probably in a lot of the same Facebook groups with doctors who are like, where are these medical bills come coming from? I'm covered. Why? Why am I being billed a hundred dollars or$500 for my, my office visit? And then everybody's bickering about, well, you, you asked a question. Are you like, no. If doctors can't figure it out, we're in trouble. And so direct primary care makes it transparent. It makes it transparent. Yes, there's prices involved, which sometimes makes us feel icky as doctors, but we have to get used to talking about what things cost, because not talking about it has allowed the fat cats and insurance companies like go to the, the depths of the extreme that they should have never gone to because we're afraid to have the conversation. So I always tell people when it comes to my practice and they look at my fees, and they might hem and haw, they're making an informed choice. To me that's means so much.'cause a lot of times they'll walk into urgent care and they'll walk into primary care offices and maybe they get an estimate. Right. But that estimate can balloon out to God knows what. If patients come to me, what's on the papers? What you're gonna pay no more, no less if we do more, here's the price for that. If you don't wanna do it, you don't have to do it. But finally we get to that level of price transparency. So that was a roundabout way of saying I think that a lot of times people think like cash pace care is ugly, but it's no more ugly than cash based to go to the grocery store. Right. It's like we, that's an essential need. Everybody has to eat. We pay cash to get that. And are there members of our society that don't have enough for groceries? No. And they, there are people and they use food stamps, which is effectively is treated as cash. We don't ask the grocer to do file a claim because somebody wants to get, a bag of groceries for the week. I think we should look a lot more like that. And so getting from that mindset of I'm gonna hurt people by not taking insurance to actually, I'm helping more people by saying we can't play this unethical, non-transparent game anymore, I think is what's more important. So again, it just, it, it depends on how people come at me. Some people are on board right away. Some people are very confused, some people need more information. But I do preach the gospel of, I really think this is the most ethical way to practice primary care. I think that might be true even in specialty care, but definitely in primary care. I think using insurance has actually hurt us so much more than it's helped us.

Maryal Concepcion, MD: 1:11:31

And I would, I would especially encourage anybody who speaks to people who might not be physicians or they are physicians speaking to healthcare policy to listen to Dr. Cook's episode here, because this is what is also frustrating on so many fronts when we're speaking at, local organizations, larger organizations, and to only fight for the insurance-based healthcare system is doing everybody wrong. It's doing us as physicians wrong because it is not allowing us to advocate and do the best by our training and our profession. And it, and it also does not look out for the health and wellbeing of our communities because when you're doing the bloat, as you just put it beautifully, that is exactly what people are fighting for when they only stand for health policy related to insurance. Right. To, to the insurance systems we have right now, blue Shield United, Cigna, Aetna. Yeah. At this time in our nation's history, healthcare and access to quality healthcare is so bipartisan. It's so refreshing to know that it's so bipartisan. But this is also where you have a voice, whether you're planning A DPC, whether you've been open for years, this is where speaking up to what you're doing, just sharing the stories of what you are doing for your patients, that's what sticks and that's what helps impact policy going forward. And this is a time when, s speaking up can really help that bipartisan vote go forward for everybody's Ben, for everybody's benefit.

Michelle Cooke, MD: 1:12:57

Absolutely. Absolutely. And it's amazing even in the DPC space where I think. There can be in this time we're just so politically divided. But it's amazing how DPC has been very non-partisan. And there are people I've met at DPC conferences who have just like very extreme beliefs from where I am. But we still connect so much. I'm like, no, but we're here for the patient. We're here for fairness, we're here for transparency. It's, this has actually helped me bridge a lot more gaps than I thought I would like being at some of these DPC conferences and connecting with people that I'm so opposite of. Philosophically, there's some people who really don't believe in what I'm doing. They're like, you're doing a black woman's practice. That's crazy. But they get it and they still back me.'cause they understand that my heart is with the patient. Right? And so I think this is very transformative work. As much as I hate what's going on in our country right now with the divisiveness and, lack of funding and DEI takedown, I think it's, it's finally the breeding ground or DP DPC is going to thrive because people are looking for a solution that makes sense and that really has a patient at heart and protects the healthcare providers as well.

Maryal Concepcion, MD: 1:13:58

Amen. So, speaking to those physicians in the audience who are thinking, wow, I, I'm actually just as I'm listening to this podcast, I am acknowledging my burnout. I'm acknowledging my fear to leap into entrepreneurship because I'm only a doctor. I'm just a doctor. I say those facetiously'cause being a doctor, there's not too many of us and there's not too many of us that are able to practice at the highest level of our training, especially when we're in corporate medicine. So what would you say to those physicians out there who might be scared about physician entrepreneurship and who might be sitting there acknowledging their own burnout Right now?

Michelle Cooke, MD: 1:14:42

I think the first thing is to acknowledge your burnout and understand it's not normal. It's not normal. And I think that's what I wish someone told me. Because I feel like there's, it was, it was normalized. Oh, everybody does it. Everybody sees 25 patients a day. Like just kind of stick with it. It's not normal, it's not healthy. Second thing I would say that it took me a while to get to is that being an entrepreneur, small business owner, it's figureoutable. I think I read a book called like it's All Figureoutable or something like that. But I had to tell myself like, there are so many small business owners who have a fraction of the education we have. Think about your hairstylist. The guy that mows my lawn, the laundry, the, the dry cleaners, like most of these people are not doctorates and they figured out a way to do a small business. And so I say that to say if we can figure out, like people say the Kreb cycle, if we can figure out how to intubate people, if we can figure out how to titrate insulin, like you can figure out how to start a practice. And the other thing I would say is that in medicine, there's always this fear of litigation. There's a fear of risk. There's a fear that a patient's life is on the line. The rest of the world doesn't think like that. It's kind of hard to imagine that, like we're not always thinking in this risk mindset, but when you get to the business side and you start like listening differently, hearing different thought leaders, it's if you're not failing, then you're not trying hard enough. There's an acceptance of failure. There's an acceptance of you're gonna get it wrong and you're gonna learn. That's the best way to learn. And there's always a way to pick yourself back up on your feet. I'm very passionate about what I do and I think sometimes that translates to people as thinking that I know what I'm doing. I dunno what I'm doing half the time, right? But I always lead on this fact that whatever's there, I'm gonna figure it out. Like I just gotta figure it out. There's always a way, there's always a path forward. And I would encourage people to even listen to the building DPC podcast because I'm very transparent about the fact that I was scared. I didn't know how to hire people. I still get help habitations. I look at my QuickBooks, there's still a lot that I don't know and I'm not good at, and may come to bite me at some point. But the, the, but the alternative was worse. The alternative is worse. Like this is, this is what I'm choosing. Because it makes more sense. I'm actually passionate about what I do. My hardest days, don't hold a candle to what my hardest day were in the fee for service. Like my worst days here just almost didn't even touch my best days when I was there. So it can feel really scary, but it's figureoutable. You're expected to fail. And in those moments where I, I doubt myself, I go back to the stories, stories are so powerful. Listen to my DPC story. If you listen to other entrepreneurs, like they've fallen flat on their face a million times, but they just keep getting back up because they're so mission-driven. So I think it, it's not about perfection. It's not about getting it right, it's loving the journey more than the destination. And like we have, if you still have gas left in the tank and years left to live you want that journey to be fulfilling. Like you're not just trying to get somewhere. I feel like when I was in fee for service, I was always just trying to get to vacation, like always trying to get to my next day off, right? Because I, I, I wanted a break from life. But when life feels great, when life is I come in with my team and we huddle every morning and we're excited about the wins we had and we're gonna see some patients who need us and we can do it in a no nonsense way. Every day feels good. I feel good about what I do every day. And And that's priceless. It's priceless. And so it does cost a little bit of courage. It costs a little bit of being afraid, but if you can get past that part, which if you were an active physician, you've gotten past that part.'cause all of us have been on call by ourselves that first night, or taken that page and didn't know like your intern year, like what the dose of Tylenol was that the nurse called you for. Like we've all been there and figured it out. And if you can face that, you can face this. It's not easy, but it's so rewarding and it just makes so much sense.

Maryal Concepcion, MD: 1:18:15

And on that note, tell us where people can listen to building DPC and find you.

Michelle Cooke, MD: 1:18:22

Absolutely. So building DPC right now is only on Spotify. It's a 10 episode series. There's a bonus episode about legal matters and DPC. So check it out on Spot Spotify, take a listen and you can jump around to see which episode works best for you. But each episode kind of outlines a different part of the DPC journey, so choosing your EHR marketing hiring staff. So it really, really helpful for those of you that just feel like completely lost.

Maryal Concepcion, MD: 1:18:46

Love it. Well, thank you so much Dr. Cook. I'm so excited to have you back on the podcast and to hear a longer interview from you this time.

Michelle Cooke, MD: 1:18:53

Absolutely. This was so much fun, Marielle.

Maryal Concepcion, MD: 1:18:58

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.