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Episode 112: Dr. Nicole Harkin (She/Her) of Whole Heart Cardiology - San Francisco, CA

Direct Care Doctor


Dr. Harkin practices in San Francisco, CA
Dr. Nicole Harkin of Whole Heart Cardiology

Dr. Nicole Harkin, MD, FACC is board certified in Internal Medicine, Cardiology, Echocardiography, Nuclear Cardiology, and Clinical Lipidology (cholesterol management).


After graduating from Boston University School of Medicine magna cum laude, she attended Columbia University for Internal Medicine residency and New York University for Cardiology fellowship. Upon completion of her Cardiology fellowship, including serving as a chief fellow, she remained on at NYU as an Assistant Attending until moving to San Francisco.


Passionate about preventing and treating heart disease through healthful, sustainable lifestyle changes, Dr Harkin works with her patients to create a proactive, personalized cardiac care plan. She is also the Chief Medical Advisor for PlateUp, a health tech start-up dedicated to improving health through nutrition, and is a member of Planted Forward, a comprehensive, multi-speciality telemedicine health team. She proudly serves on several committees, including the American Society for Preventive Cardiology Nutrition Working Group and the American College of Cardiology California Chapter Prevention Committee.


She currently lives with her family in Tiburon, CA. When not doctoring, she spends the majority of her time with her three young children. She also enjoys cooking, yoga, Peloton-ing, hiking, and traveling.



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Transcript*

 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 DP C story podcast, where.


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, D P C, 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. 




 Direct specialty care for me is being able to practice medicine and preventive care in particular, in the way that I want to practice it. And so being able to connect with my patients in an in depth level and really help them get to the root cause of their cardiac risk factors is it's just incredibly rewarding. I'm Dr. Nicole Harkin of Whole Heart Cardiology and this is my Direct Care story.


 Dr. Nicole Harkin, M D F A C C is board certified in internal medicine, cardiology, echocardiography, nuclear cardiology, and clinical lipidology or cholesterol management. After graduating from Boston University School of Medicine, Magna Cum Lai. She attended Columbia University for Internal Medicine Residency and New York University for cardiology fellowship.


Upon completion of her cardiology fellowship, including serving as a chief fellow, she remained on at NYU as an assistant attending until moving to San Francisco. Passionate about preventing and treating heart disease through healthful sustainable lifestyle changes. Dr. Harkin works with her patients to create a proactive, personalized cardiac care plan.


She's also the chief medical advisor for playup, a health tech startup dedicated to improving health through nutrition and is a member of Planted Forward, a comprehensive, multi-specialty telemedicine health team. She proudly serves on several committees, including the American Society for Preventive Cardiology Nutrition Working Group, and the American College of Cardiology, California Chapter Prevention Committee.


She currently lives with her family in Tiburon, California, and when not doctoring, she spends the majority of her time with her three young children. She also enjoys cooking, yoga, Peloton, hiking and traveling.


  Welcome to the podcast, Dr. Har.


Thank you so much for having me. I'm super excited we were able to make this


work. Absolutely. And you know, we were chatting a little bit about you being a specialist in this movement of direct primary care as a business model.


And it is so awesome that even though yes, you have just gotten started, like I was mentioning, you know, so much more than most specialists out there. And so it is such a privilege to have you share. Your perspectives as a cardiologist and as a specialist on this podcast for other people who are listening in about the direct primary care model and wanting to follow it.


So I wanted to start with the fact that you went from Boston to Columbia to nyu, and now you're in San Francisco. So can you please share with the audience about your journey into cardiology and what was life looking like prior to opening


your own? Yeah, absolutely. So, I'm actually originally from the west coast, so I feel like I've kind of come back home uh, in many ways.


So, yeah, as exactly as you said, I was in, on the east coast for much of my training. Cardiology was interesting for me. I actually really thought that I was gonna do infectious disease, interestingly enough. That was like my thing. I was really interested in international health, did a lot of work abroad that I was.


Mph and I wish I was, could say there was like some seminal moment that occurred that made me completely shift and change my trajectory. And probably the closest that I can pinpoint it to was actually I was in um, Africa doing some, some work in medical school. And I started to really realize that yes, the burden of HIV and malaria and communicable diseases is profound.


Actually, I was shocked by how much chronic disease I was seeing hypertension, you know, cardiovascular disease, complications, congestive per and then just really at that point started to really completely I guess, internalize that cardiovascular disease is the number one cause of. Globally. And so in terms of impact and obviously I think the heart's super cool and it's interesting too and the path of physiology and the physiology.


But yeah, just in terms of impact and if I really was thinking about public health, maybe I should kind of explore this. And and then I ended up at Columbia for, for residency and Cardiology's a very strong program there. And you can't help but like love cardiology when you go there. So that was sort of my path there and kind of how I landed in cardiology.


And just really you know, it's, it's super interesting. I find it obviously, as I said, the heart really fascinating, but in terms of what I'm specifically practicing now within the field of cardiology is prevention and that's always sort of been my jam and sort of how I ended up back in kind of, I would say more.


Public healthy type thing, which is, you know, the prevention of cardiovascular disease. So, that's been kind of my journey and, and how I fell into cardiology. And I absolutely, in, in my practice, love preventing cardiology, treating cardiology, using lots of lifestyle and precision medicine.


Incredible. And you know, just you sharing that really, really adds to why you are a preventative cardiologist and a person who specializes in lipidology as well, in terms of being able to give as many details and evidence based to a patient in their personalized health plans, which we'll get to to prevent the diseases that we spend so much money and time on.


As you well know, and most of us in primary care know could be avoided. So with that said, how did you go from, loving this place of really being able to make an impact preventatively to opening your own direct care clinic? Because it's definitely not a common thing to see a specialist choose a model that is separate from the fee for service.


Yeah, absolutely. So certainly not something I ever envisioned I and thought I was going to do. But certainly I would say those of us who I think most of the DPC docs as well, who are really invested in well care and prevention and spending time with patients, it sort of just naturally ended up evolving.


So, after finishing. Cardiology fellowship. I worked in traditional private practice for a number of years. I had my first child towards the end of fellowship. And then over the course of the next couple years, had two more children. So, was also working in, I would say, a more part-time capacity, although for, you know, a doctor that's like, what, 40 hours a week?


And and doing that and just kind of chugging along and doing my thing and. actually it really was a, and again, very focused on prevention. So I tended to see a lot of patients, lots of the classic cardiology type patients that you would expect. But I also started attracting a lot of people who were really interested in prevention.


So people with a very strong family history or a lots of risk factors or whatever it else just, you know, being like, is this all there is, what should I be doing? You know, how can I make sure my dad had a heart attack at. I'm 45, what should I be doing? And so started kind of building a, a larger panel of those patients when I was in New York.


And as everyone here listening knows, those types of conversations take a lot more time. And it's not as simple as just, you know, handing out a medication and and unfortunately is not super well suited to sort of the traditional insurance based model where cardiologist is lucky if they get 10 minutes with a patient.


So that was sort of what I was doing and just kind of plugging along. And then honestly it was life circumstances. My husband's job, he got transferred and we moved to the Bay Area and I had actually just had my third baby and so she was a couple months old. So took just a deep breath and took a step back and we were deep in the middle of the pandemic.


This is 2020, right? Summer of 2020 when we moved. And so, just kind of did a lot of self-reflection. Like, what do I wanna join? You know, a Kaiser here or U C S F, do I wanna look for another private practice job? Like, what is it that's gonna make me happy? And honestly, it was some of the, the doctor Facebook groups and I saw sort of direct care being mentioned.


Eventually sort of, there's a, you know, a California based one for dpc. And then there started being some specialists talking about direct care. This is like, sounds like a dream. Um, So started learning about it. And, and that's when I, I just like, I'm gonna do it. And it's not very much like me to take, just like jump for something like this, but decided to go for it.


Launch, and I'm sure we'll talk, get into this more, but launch telemedicine at first and, and now in person. And


as you share how, you know, that's not your, traditional way of going about life in terms of just jumping into something, like leaving fee for service and opening your own clinic.


Given that it was like you were being guided by what will work for you and your family and the way you want to be with your patients. When you came from this area where you had a panel of followers who were really, really wanting to do preventative cardiology to San Francisco, where that's not too much of a, you know, a, a hard jump to make in terms of wellness is definitely appreciated in the Bay Area.


Coming into? A community that might have been proactive with regards to their health, but in a place where one medical access is pretty much everywhere


um, where there is a, like you said U C S F Kaiser, where there is a lot of specialty access, how did you have any hesitancy and what were they in terms of, you know, how would you build your patient panel marketing and how would you, Opening your


clinic.


Absolutely. So I think one of the biggest hesitancy that I had was just


will this


model work both from a patient acceptance standpoint and, and then just kind of financially like, can I make the numbers? Work in such a high cost of living area. . And, and then exactly as you point out, you know, and I guess this goes along with patient acceptance.


Certainly the Bay Area is dominated by Kaiser more than anything. , and people are, you know, very much in that system. If you're in that system, you're in that system and that's it. And so people aren't sort of used to. Stepping outside the box and thinking about, you know, seeking healthcare on their own.


It's the type of a commodity that, as again, your listeners are super well aware of, is really different than a lot of other ones. And so, and we're used to just going with our insurance. I think the, the environment is changing a lot and I think people are starting to really realize that the quality and the type of care, like if you're well and have no issues, it's maybe not a big deal, but if you really want.


Sort of high touch care where you can get ahold of your doctor. Things are different. And so, so I definitely worried about that. I think within, thanks to your podcast and lots of other venues, I feel like DPC is starting to be pretty well known at this point. And so I felt like the model for primary care office was pretty well established, but I just didn't know and still am not a hundred percent confident that it will work for, for a specialist.


Because, you know, it is, it is different. It's in some ways a very different model. and again, we'll probably get into that, but I, I, as of now still have not launched membership. It's still sort of the, the one offs and things like that. And so, so it's a different sort of financial model and, and offerings and things like that.


But I just again, came back to the fact that I feel like people. Ultimately, once they realize this is an option, we'll be willing to pay for better access, better care and those sorts of things. So, so definitely had a lot of hesitancy about, you know, if this type of a model would work. And then also moving to a new city and not having a network yet.


Right. So I, in New York, I could think of, you know, concierge and some direct care and outta network. Reasonably well accepted in Manhattan, and I knew a lot of people that were kind of doing it. I didn't know anyone or anyone doing it in the, in San Francisco when I moved here. So,, it was a little intimidating to think about trying to build up a network, a referral network, and then just kind of better understand the lay of the land.


Yeah, I definitely , appreciate that. Especially cuz you know, in a seven square mile area there's a lot of people, but at the same time finding your, your niche. And then having people latch onto that That, those are, those are challenges.


I could easily see in any metropolitan area in addition to San Francisco. So did you strategically plan on opting out before you opened? And how did you start seeing those first patients? Did you see them in your office space or did you open with a telemedicine practice?


In addition to an office space?


Yeah, so when I opened we were still deep in the pandemic. I had a lot of these sorts of question marks in my mind about the, the model. So what I did decide to do, and, and frankly, I still had a very, very small baby and I kind of wanted to just be selfish and she was my last baby and spend more time with her.


So, I didn't wanna, Full on into all that is in terms of building the, the physical space. So I launched telemedicine only. And at first it was a lot of my New York patients just, they found me online. I got, you know, on social and built a website and all these things, and they sort of, Started to find me.


So that was the bulk of, kind of the initial parts of my practice and then started, you know, getting patients off of various other, you know, social media and podcasts and various other ways. And, and then networking as well. So I sort of hedged my bets a little bit and wanted to kind of start with a very low budget model and see.


If just what the response would be and just kind of test the waters and, and use that time to sort of talk to people and, and get a better understanding of kind of the lay of the land, as I said. So that was sort of how I, I started. And then it wasn't actually until this year that I decided to open my doors physically in person.


And when you opened, had you opted out of Medicare to start or did that come after you had seen some


patients in your clinic? Right, as a cardiologist, I was like, hmm. This is gonna be a little interesting if I can't see anyone over the age of 65.


But again, was not sure what the response would be, so I decided not to opt out to start. I toyed around with the idea of hybrid approach, but again, because I was telemedicine only and I wasn't sure what was gonna happen with the regulations vis-a-vis telemedicine and Medicare I decided just to kind of hang tight.


For that first, I would say six months to a year it was still very low volume and just kind of exploring, figuring out what was working, what wasn't. And so, decided not to see anyone that had Medicare, didn't formally opt out, but was collecting email addresses and names and just said, you know, I gotta figure this out.


If you're interested in seeing me, I can't see you at this point, but please let me know. So started collecting. And I think, you know, people could do it one of two ways, I think. And again, I think if I hadn't been telemedicine only, I would've started sort of hybrid accepted Medicare patients, build Medicare, and then opted out once I started to kind of build that list up enough.


, and then I would, . I guess after about a year or so, I decided to just go for it and opt outta Medicare. Um, So I'm opted outta Medicare and and that's been great. And you know, I think the biggest bummer is that I do provide, as I said, I still bill for appointments as opposed to a membership model.


And so I do provide super bills. And so for my patients who have ppo. It's nice that they can kind of submit and get something back and things like that. And unfortunately because of Medicare it's a bummer they're not able to do that.


Definitely, and, you know, hopefully regulations change in the future in terms of access to healthcare roadblocks.


So in terms of when you think about, you know, how you approached your decision to opt out and how in the beginning you weren't opted out and then you decided to. Can you give any advice to other specialists who might be in that same position of, do I opt out or do I not?


What should they think about if they're considering opting out depending on their specialty?


Yeah, absolutely. I think for what's good to know is that even if you opt out of Medicare, you can still prescribe, you can still order tests, you can still order labs. I don't think I totally realized that at first.


So I think that's important for, for providers to know. And and I think that's a good decision, tree point. And then I just think also thinking about sort of your mix and it maybe for if you're. Established and you're going more in the direct care route. I do know of a lot of specialists that kind of decide to just keep Medicare and then opt out of all of the, the private pairs.


So that's a good way to do it. And then just talking to your patients and sort of seeing what that, the appetite is like and what that looks like. And it may be that once as. Reimbursements for Medicare continue to drop and drop and drop it no longer kind of works for you. So that might also be part of the decision.


But I think having faith in your model, which is something that I didn't totally have at first, is really important. And so if you really have this confidence, like this is something people are going to want it, it's cleaner and simpler just to opt out right away. And just be completely direct care.


So there's just like no confusions and no you know, Things to happen depending on the insurance and just being completely insurance agnostic.


When it comes to the way that your model has been set up you shared earlier how you're not necessarily on a membership basis, but you are on a, pay per visit setup.


And so in terms of you deciding how you would structure your. Payment options on your website, you have different blocks that people can schedule an appointment for. How did you determine your pricing and going into the future, do you foresee a membership helpful for certain types of


patients?


Absolutely. So I wanted to start without a membership. And I think that will certainly continue to be a, a large part of my practice. A lot of my patients do come from internists who are, they're already paying a membership, right. And so I just, I didn't want to Have yet another membership that people had to then choose that they have both or what, and just seems like a little bit duplicative.


So, and there's lots of people that'll come to me, you know, just for a second opinion, and they just need to, you know, confirm and have me review everything. And, and then that's that. So I will always have that. And I think for specialists it, it makes sense. You, you need to have kind of that option.


But I am increasingly realizing that the need for a membership particularly for someone like a cardiologist who does manage chronic diseases and we're doing lifestyle changes and there's a lot of kind of back and forth over portal messages and a lot of frequent visits and things like that.


So, so I'm actually working with someone right now to kind of. Set up the structure of how that membership would look like for people who do wanna engage with me and, and have more follow up appointments and things like that. So I imagine that in my membership it will be unlimited visits, unlimited communications, you know, et cetera, et cetera.


For, for people who just want that even more close follow up and, and tighter level of.


Gotcha. And just getting into the uh, logistics of your practice quick you have chosen charm for your emr, and so in terms of this potential of having memberships in the future, did you choose your EMR based on having that potential, or do you see yourself switching EMRs because of certain needs that you might have going into the future because


of member?


Great question. No, I was not that savvy to think about that, that part advance. I wanted something, I actually was really attracted to Charm because of its buildability. And so I really like the idea that particularly as someone who was just starting out and sort of dipping their toes, wasn't totally confident in my model.


You can just build what you want, right? So it's literally free in thats base version, which is what I started at, and then you can add the things that you need. So I slowly added, you know, ere prescriptions when I decided I prescribed was too much of a pain in the bootie to go on the separate thing.


So, you know, you just kind of, as you get busier, you can build and in things in there. So I really actually liked that. I also liked that it was very automated, so I really didn't wanna have anyone else in. Set first. And so , you can set up all the reminders. You can set up the questionnaire. So as, so basically how my workflow goes is , someone can book the telemedicine appointment on the website directly themselves.


So you can do a web embedded calendar. Once they book it, my EMR will directly send them a, a welcome link to the patient portal. They'll also automatically get all of the documents they need to sign and fill out. They can upload everything there that they need. , and then there's patient reminders and you know, a lot of it was really, Tech friendly.


And I know a lot of them have that, but this one I just, I, I trialed a couple out and it just worked with my brain as well, which I think is important. And you can build templates, you can do dot phrases, I mean, just stuff that I kind of wanted and it doesn't have a lot of the stuff that I. Didn't need, you don't have to have any check boxes if you don't want them.


So I liked that. And then, yeah, I just liked the buildability of it. You can, so I did reach out to them through charm. You can bill someone monthly. So, so I will start probably with that. I know Hint is very popular at dpc, so we may switch over to that depending on , what it all looks like.


Um, So I'm still figuring that part of it.


Now getting into the, personalization that you bring to your patients, I just love, love, love that it's so clear


on your website


everywhere you're looking in your logo, that you are about prevention you mention that you bring comprehensive personal family history discussions to your patient visits and then talking. Then you talk to your patients about dietary risk factors, lifestyle modifications, things like that. Can you give us a, an idea as to what it looks like when a patient says, Dr.


Harkin, I'd love for you to be my cardiologist, even if it's for a second opinion. How does that look like at their


first visit? Yeah. They'll get my intake questionnaire. It's, it has all the standard stuff, but I do also ask sort of early things about lifestyle.


So I like to have kind of a jumping off point so that I know kind of where they're at. So we can kind of frame that convers. So I do ask about nutrition, movement, stress, sleep and I have some rating scales about behavior change. one of the first questions I ask is, what are your goals? And what do you wanna get out of this?


And why do you want me to be your doctor? So that I kind of know how they're approaching this and what's important to them. So those are the things that I know going into the appointment. I also, as I said, have. Anything that they've had done before. So if it's a second opinion, for instance, obviously all the relevant testing, I like to see all of that, if they've had any heart testing or recent labs, all those things.


So, I ideally have all of that in, in hand going into the appointment. And then the appointment itself is, you know, really going into depth into all of these things. So I like to understand it. They have hypertension. When was it first diagnosed? what medicines had they tried and what order and how did it respond? Family history and all of those things and sort of identify so if this is someone for cardiovascular prevention, what are the main risk factors?


You know, lots of questions about secondary causes, you know, is there. All the questions about obstructive sleep apnea. Is there any excessive tiredness and morning headaches and snoring and yada yada ya. So there's a lot of that in terms of the lifestyle questions.


, for instance, in terms of nutrition, a lot of things I like to go into, I'll do sort of like a 24-hour recall. I usually do kind of a typical breakfast, lunch, dinner. I ask how often they have red meat, how often they have processed red meat. I ask about kind of typical snacks if they snack, and when I ask about desserts, I ask about beverages, obviously alcohol and things like that.




So during the visit we as we're going through these things, I you know, make comments about different things and different tweaks throughout the way. So I'll usually make some suggestions. Typically, I'll either start with kind of the low. Fruit, like the easy stuff to switch and or the stuff that, that they feel like is doable, that's gonna move the needle the most. And then we kind of create I have them be very much engaged in that decision about, after I've done some patient education about, we wanna try to overall reduce your saturated fat.


Cuz I, you know, I see that, that there's, , certainly a significant amount of saturated fat in your diet and this is where it comes from and, you know, they kind of already have sense and then we talk about, okay. Which ones feel doable and is it the charcuterie that you're having for five times a night or whatever?


Let's, let's, let's decrease it two times a week or whatever, you know? And then I literally type out that that's my goal, and then they get a list and I, I try to start with like two or three changes at a time, so as not to overwhelm them.




We talk about kind of a testing plan if there is further things that we wanna get to, to better fine tune and, and better understand their risk. And then afterwards I send them a summary of what we discussed.


And I do have different handouts that I give them to kind of refer to some of the education that I provided during the visit as. And then they're always welcome to message me between visits on the portal to kind of let me know how things are going or if they're experiencing roadblocks and and we try to troubleshoot there








and


in regards to the time that it takes for


you to review their,


Intake forms their, cardiac studies or labs that they might have uploaded doing. Patient visit and then creating the summary About how much time do you dedicate for the administrative part versus the inpatient person part, whether that be via telemedicine or in in physical person.


Yeah, so the patient face to face visit, they're booked for about an hour. , and I try to give myself a little 15 minute block afterwards. I documentation, whether direct care or not is always, I find the most challenging part um, especially since I send them summaries afterwards. But honestly, those are invaluable.


They love them because I, you know, as everybody knows, you walk out and you're like, wait, what did I just get told? You know? And so it's really good to have that in. So they can see it. So, and that's exactly as I've explored this, I think definitely not accounted for the administrative time enough particularly when I first set my prices.


And so that's definitely something I'm reviewing now currently as I go into the new year about how to reset those prices so that they reflect not just that hour. But all of the administrative time before all of the administrative time after, and then all the portal messages that I get in between.


Because again, as someone who's just charging kind of that one time visit, I need to be able to charge enough that I'm capturing all that other time. Even. And then also, even though I'm, I'm very much a, a lifestyle first when possible. I have lots of patients on me panel who have established cardiovascular disease and we use a, complimentary approach.


So I do prescribe a lot of PCSK nine inhibitors, all of those kinds of things, which as you all probably know, require a lot of paperwork to get the prior oaths and doing them every year, and yada, yada, yada. So there's a lot of that time as well that I haven't fully, adequately captured. Um, So I'm looking as I look into 2023, that's definitely on the agenda.


And I love


that flexibility, you know, with you realizing as you've gone into, you know, more months and your first year of this practice, figuring out what are you bringing to the table in terms of your time and how to have your numbers reflect that. I think that's so important and it's a perfect time of the year to do that.


With the new year starting, it's a great excuse to say, Hey, new year, new pricing.


So, right. Yeah. Well, and and honestly, your patients will tell you too, I mean, after like probably the 10th patient was like, by the way, you should either start charging me for these portal messages, or you need to raise your price.


Like, I was like, okay, like literally a million patients have now been like, charge me for the portal visit charge me for the start. I'm like, okay. Like they are at the, you know, I especially have a lot of, I have a handful of lawyers and they're like, this is absurd. You're giving away your time.


This is not okay. So, so yeah, once your patients start telling you, you know,


it's,




Awesome. Now, in terms of the testing that you are talking about once you determine like, great, you've had the workup up to this point and you know, additional tests like a calcium score or different blood tests could be helpful, how do you talk to your patients about, Hey, okay, so I get that you're already paying me cash.


You may or may not have a direct care physician, you know, in addition to me. Here are the options for what is standard of care and this is what is and what is not typically covered by insurance. , how do you approach that conversation with them? Great


question. Because as much as we all wanna be out of network and not deal with insurance companies, they are in our lives.


So, yeah, so that is, so with lab testing, so I have contracts with both Quest and with LabCorp, and so I just, I do give them the option, which one, you know, is your insurance quickly, like most people know. And then I send them there. And so they get the testing through their insurance. And then insurance covers what they wanna cover and don't cover what they don't wanna cover.


Um, but. Unfortunately are, are used to that. Right. So they don't ever really get surprised by lab bills cuz they've been getting 'em for decades now. Right. So I think people have a pretty good sense of, of that. If they have a DPC doctor, obviously that is, preferable and then we just run it through there.


Say if they have Kaiser too. I mean, so I have a lot of patients who I, I was very surprised who, who found me and they have Kaiser and they're like, I'll keep my Kaiser for whatever. But I want to be able to like call my doctor. And so, I will often they'll have a, a provider at Kaiser that I can kind of give them a wishlist.


And a lot of them are, are pretty accommodating and they'll, they'll order testing. I, and I'm, I try to be. Thoughtful about the fact that, you know, let's try to, you know, not everything under the sun. And so, so we'll do we try to get just creative that way and, and try to make sure that we stick within boundaries.


And, you know, I, I stick with evidence-based testing um, in terms of the testing that I do. And most of my patients, I will get some sort of advanced lipid testing at some point. And so either I look at a O B or LDL particle um, lots of evidence to show that. That correlates with cardiovascular risk much better than just LDL cholesterol.


Particularly if there's any signs of insulin resistance. So that's a, a big one that I get. It also captures that LP little a, which I follow the European lipid guidelines that should be checked in everyone. It's. Some point in their life. We don't have medications now, but it does change your LDL goal and we will have medications in the future.


So, so that's captured , within that panel. You know, an hs, C r P, those sorts of things. And then I like to look at fasting, insulin, glucose, those sorts of things. And, and a lot of that is, tends to be pretty standard and, and covered by insurance. So that's how I handle that part. In terms of testing.


Because of how our insurance is set up. If you have symptoms you can get testing. So I can order. If someone has symptoms that again, runs with their insurance they can get echoes and stress tests and whatever testing they need. When you look at prevention testing, unfortunately a coronary artery calcium score is never covered by insurance.


Really? Luckily, around the, the nation the coronary calcium scores are, are really fairly affordable. So most places it's a hundred dollars. Some places it's $80. Some places it can get up to about $200. But that's typically with, you know, most people that are finding our services that's within, you know, that's feasible for them at some point.


So if that's indicated we talk about that and review that test. And then I tend to use a lot of the freestanding radiology centers, cuz those tend to be much more reasonable. , and also more pleasant. And you're not, Hospital for like three hours. So I do the, do those and then when I need things that, that do more advanced testing , than we do that, whether it's, you know, a catheterization or an increasingly actually using CTAs in some of , my younger patients with strong family history for prevention.


and again, those, if they have symptoms go through their.


And previously you mentioned that you have been able to create super bills and use reimburse with your patients. Have you had much success with your patients using ified?


Great question. , I'm not sure why, but they don't tend to use reimburse as much.


I have it on my web. It is, goes out in a message with the super bill. They tend to just file it on their own. I'm not sure if they've started getting very comfortable with it or what have you. But most of my patients with ppo, I think are starting , are pretty comfortable with just kind of getting that file on their own.


Gotcha.


And then with you focusing and having the time, which I love, cuz you know, it's, it's like going back to what you can achieve in a 10 minute visit is very different than what you're doing now. I, I wanna just highlight again how you are so educated in regards to your board certifications in internal medicine, cardiology, echocardiography, nuclear cardiology and clinical lipidology. When it comes to being board certified in lifestyle medicine, where do you feel that is important and do you plan to be board certified in the future , in regards to lifestyle medicine specifically?


That is


a great question. And one, I, I mean, I think as doctors were like addicted to education and things like that I decided five was enough for now because as is I just started my internal medicine lifestyle knowledge pathway. Oh my gosh. So, so it's a. Even though I do a lot of CME on my own, I think to keep up the boards, you know, is definitely a lot.


So I will always keep a lot of my core ones. And then I think as things evolve, I have explored both obesity medicine boards as well as lifestyle boards. Those are kind of. The two that are on my wishlist. I will say that I feel like you can also as a physician take advantage of the conferences and the material and the education and not necessarily get the board certification and feel really competent in those areas.


So, um, that's sort of where I've been. I go to, some of the different meetings and do a lot of their, they have tons of virtual CME type content as well that you can purchase. So, That's sort of where I've landed on those just because I kind of capped myself off.


I love that.


Given that we're recording, you know, during December, it's like you could put, you know, board certification on your secret analyst, I haven't seen that yet. So you might, you might surprise someone by doing that. So. No, let me ask you about, because you have this autonomy to choose what happens in your clinic when it comes to the tech that you have.


We talked about the emr, but in terms of equipment that you have, now that you have a physical space, how did you choose your equipment? Because you are taking advantage of standalone, you know, radiology centers. Did you have a big investment in the overhead when it comes to equipment in your office?


So great question and very timely ones. So as of now, I have stuck with just EKG and blood pressure monitor. I am looking at different refurbished ultrasound machines right now. Those guys are ex. Expensive. So we're gonna look refurbished. And there's some great options out there. So that'll be the big investment.


, either this month or next month. I wanna be able to do echoes and credit imts. So that's, that's coming up. And then, and then the next stage is going to be sort of figuring. Um, Some additional staffing. So I have an virtual administrative assistant who I love and she helps me make sure that all the things are happening you know, documents get back to referrers that need to get to and all that stuff.


So that's been instrumental. I probably hired her not soon enough, so that would be my other tip. Don't wait until you're like, I can't do this anymore. Do it sooner. so that's been great. I still wanna stay very micro practicing. I love that model, but, but that, some of that stuff I don't, I don't need to be doing.


And so she's doing that now, which is great. And then right now I'm toying with the idea and I've been talking with trying to figure out if I can get a per diem echo tech so that once the, I purchased the machine, although, Can and have done many, many echoes in my life. I'd prefer not to be doing them all.


It's a, it's a decently long test, so that's gonna be the next stage of the practice. And then eventually I do wanna be able to do stress testing as well. So the next big purchase will be the, the stress equipment.


And when you talk about this and I hope that you can find an echo tech, maybe like in training in school, cuz you know the city is, is chalk full of people getting their education.


Mm-hmm . But when you decided to open, cuz you're on Sacramento Street, how did you determine which space you were going to have for your clinic? And did you get your space with the intention of having a place for stress tests, a place for echoes, et cetera?


Yeah, so space is a really great question and one that I stressed a lot about.


So initially when I decided to open up a physical space I was looking high and low for a sublease. Like I really thought, you know, I only wanna be in person a couple days a week. Why don't I just try to find a sublease? And had one that ended up falling through because she decided to kind of close things down so It was a process. Um, So I would say if a sublease is an option, that's a great way to start for a lot of people and what a lot of people do. I just, I, it didn't end up sort of working out. So I was able to find a space that I could sign just a one year lease. On just so that if my needs, again, continue to evolve.


And I chose sort of an in between size space. So I have a waiting room and then two offices. So I have my own personal office where I, do the kind of the initial consultation part and then an exam slash where my echo will go, echo machine will go. So, And it, that room is big enough that I wanted to get a treadmill in there.


I could. So, um, so it's big enough that I, it can work for some period of time but not so, so big that the overhead was like crazy, which in San Francisco was a, a serious concern.


Absolutely. Oh my goodness. It's crazy how, especially during the pandemic you know, real estate went insane in this whole state, but especially the city.


So when we talk about how you moved from New York to California, you're also licensed in Florida. So how did you decide to become licensed in Florida in addition to New York and California? And are you looking to expand your licenses to other


states as. So great question. As I have done more and.


Things on social. I do get a lot requests for other states at this point. I'm not looking to expand unless it, it makes a lot of sense for the practice simply because I'm really kind of focusing on, as strange as this may seem, sort of my local footprint and really expanding here. so that's sort of where the focus is, although at some point I may continue to get additional licenses.


A a preventive cardiologist is difficult to find, unfortunately. Particularly one who's really focused on lifestyle and plant forward nutrition. So I get a lot of requests from. All over. , so that may happen , at some point in time. But yeah, I mostly wanna focus on, on kind of making a name for myself here.


And honestly, I did not realize how much I missed being in person and seeing people in person. I, you know, I have this great relationship with so many patients and it's so strange to me that I've never actually met any of them in person or many of them in person. so I'd like to kind of really focus on that.


Florida was an easy one because they have a telemedicine only license. So they basically, if you're licensed in any other state, they'll recognize that license. You just have to apply for, I think it's like a permit is what they call it, basically. and you have to pay, I think it's like $20 a year to have some sort of address in Florida.


So , it's pretty straightforward. and a fair amount of my patients in New York, spend time in Florida as well. So it definitely made.


It's very different than the 800 plus dollars that we have for our medical licenses. And it just went up this year in California. So that's so different to have $20 as a, as a permit charge.


So , even though you talk about focusing on your footprint locally, you're definitely making a huge impact nationally. On your website you have, you know, multiple resources that you've been quoted in or featured in, and I love that because by doing that, you help bring awareness to the fact that other cardiologists and other specialists can do direct care.


And the importance of having. A physician who knows you. So with that you've been able to collaborate with different people, different companies. one of the collaborations you have is with Planted Forward working with Dr. Melissa Mandala, , who's been featured on the podcast before, as well as play up.


So can you talk about your collaborations that you are so excited about and how you decide which collaborations you'll take?


It's a great question. I don't do a very good job at saying no, so that's probably that part. No I think exactly as you said, sort of the more awareness we can bring to sort of a different way of practicing medicine and that you don't have to be.


Miserable with your current medical care. I mean, I came in, I mean, you probably hear this too, like so many people get on the phone with you for like the meet and greet and they're like, I just hate my doctor. I hate not the person, but just the system or whatever it is. You know, people are really sick of it.


So, I think just, you know, bringing awareness to the fact that there's , other ways or modalities that you can get medicine. And for so long a lot of the out of network providers were not necessarily evidence based providers and . And so I think at first you started get lumped into this group of, you know, Other types of providers.


And I think it's, and, and at least from the view of the lens of the traditional medical providers, they think anyone that's charging cash, they must be doing, they must be like whack jobs, right? And so I think now we're finally starting to bring up, this is probably not at all PC to be saying, but it's totally the truth.


People are like, wait, you charge cash? Like you must be like, you know, Whatever, prescribing ground up pig hormones or something. So , so I think people are starting to realize that there, there are like great good doctors that just wanna practice medicine in the way that they wanna practice it, that are providing medicine in a different way.


And so you don't have to be stuck in like that model. So both from a patient's. And a provider standpoint, like there's other docs you can refer to, you know, so I think educating people about that, also educating people about lifestyle medicine and about plants in general are very health promoting and how we can change the way we eat and move and sleep.


Is, is really. Full in terms of, our health. And so a lot of the collaborations that I've chosen to focus on really do sort of emphasize that. And, you know, it's, it's not enough to just tell people that, but kind of giving people the, the tools to do those things. And so with Play Up actually that's one of the, companies that I am a chief medical officer for, and that's been really, really fun.


it's an app actually that I think a lot of DPCs might really find helpful with their patients. So it's a free app that you can download. That allows patients to not only track kind of their, what they're eating, so it's just they take simple pictures of what they're eating to kind of log their food.


And they can also meal plan and there's a social aspect where they can explore different meals and things like that. And then my favorite part about it that we're really building out right now and focusing on. Is the interaction and the collaboration that you can have with your care providers. So you can connect with your doctor or RD or health coach on there as well.


So they can sort of see at a glance kind of what you're eating on a day to day basis and kind of help you make recommendations and changes there. So. Awesome.


And you know, as we see how. Society is really craving quality over quantity when it comes to healthcare. It's such a perfect fit that you are doing , preventative cardiology and making an impact again nationally.


So thank you so much Dr. Harkin, for joining


us today. Thank you so much for having me here. This was really fun.


 Next week look forward to hearing from Dr. Amber Becken Hower of the Healthy Human D P C in Blair, Ashland, Nebraska, and yours truly as we have a candid conversation about life, D P C, and what's been going on over the past year at Bigtree md. If you've enjoyed the podcast, tell someone about it. There are still lots of physicians who have not yet heard about DP C and you can help change that.


It also helps others to find the podcast if you leave a five star review on Apple Podcast and on Spotify now as well. And follow us on social media, help support the work the podcast is doing and celebrate the end of season two by. Snagging some DP C swag, like t-shirts, mugs, and more by visiting the DPC swag.


Shop today@mydpcstory.com. If you're wanting to continue learning more about DPC in the meantime, check out DPC news.com. Until next week, this is Marielle conception.

*Transcript generated by AI so please forgive errors.

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