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Episode 130: Dr. Ryan Neuhofel (He/Him) of NeuCare - Lawrence, KS

Updated: Jul 14, 2023

Direct Primary Care Doctor

Dr. Ryan Neuhofel of NeuCare - Lawrence, KS
Dr. Ryan Neuhofel

Dr. Ryan Neuhofel is a board-certified family physician. He was born, raised, and (mostly) educated in Kansas. He received a B.S. in Biology from Friend's University and a Master of Public Health (MPH) from the University of Kansas prior to medical school at Kansas City University (DO). He completed his Family Medicine residency training at KU-Med where he served as Chief Resident.


Shortly after finishing training, he founded NeuCare in 2011. He now lives in Lawrence with his wife, 4 kids, and 1 Labrador Retriever. When not cleaning up after his children or dog, he enjoys cooking, fine ales, and the great outdoors.







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Address: 3320 Peterson Rd, Ste. 10, Art Executive Park, Lawrence, KS 66049

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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 DPC Story podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen.


Into 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 Primary care is the way I am Dr. Ryan, new Hoff of New Care, and this is my D P C story.

Dr. Ryan Fel is a board certified family physician. He was born, raised, and mostly educated in the state of Kansas. He received a BS in Biology from Friends University and Master of Public Health from University of Kansas Prior to medical school at Kansas City University, he completed his family medicine residency training at KU Med where he served as chief resident.


Shortly after finishing training. He founded new care in 2011. He now lives in Lawrence, Kansas with his wife, four kids and one Labrador Retriever. When not cleaning up after his children or a dog, he enjoys cooking fine ails and the great outdoors.


Welcome to the podcast, Dr. Newh Huff. Thanks. You know that we're recording this, unfortunately past, uh, may the fourth be with you, but I love it. This is the way people, and that is not even something that you can take lightly when Dr. Newh Huff opened his practice over a decade ago, so that is incredible in 2011.


So let's start there. Back in 2011, you had opened pretty much out of residency and we hear people doing that more and more these days, but this is 2023. So back then, did you even, you know, think about fee for service as an option after residency, or did you always want to do a non fee for service model practice?


Yeah. Well, first of all, thank you for making me feel very old. Uh, so I, I'm sure my story changes over time cuz you get older, you know, you reflect on it and, and try to remember what you were thinking at the time. But I, I, the way that I remember is. Is towards the end of medical school, which for me would've been 2008.


Makes you feel even older. I knew that I wanted to do primary care, but I just didn't see a way that I could do it in a way that I envisioned myself being a family doctor. So I, I wasn't in a state of despair about that. Cause I knew I had to go to residency and I didn't have to decide tomorrow. But when I looked at what, what my career path or what my five or 10 year plan was, I, I knew, man, I, I don't know what I want to do when I grow up.


And so, you know, I went to family medicine residency. I knew I would have to just do what everyone does. But I know by the time I was an intern, I knew I wanted to do some type of alternative. Practice model. And, and I think I read, uh, a few articles, 2008, 2009, uh, I think, uh, Dr. Garrison Bliss in Seattle was the first one I read about and thought maybe this is something that I could do.


And so I did a little bit of research, but there wasn't many people doing, uh, what we now call direct primary care. And certainly using the phrase back then, uh, I think there was only a handful of mentions on the internet in 2009, 2010. And so really my, my second, third year of residency, I, I kind of formulated a business plan and, and wrote that all down and spent my little free time in residency getting ready to open my practice.


So I, I never took a job or worked in any other setting outside of, you know, residency in primary care. I did a lot of er moonlighting, uh, for financial reasons, but, uh, no, I never worked in a fee for service and never considered it, and started my practice about six months after I graduated residency in December of 2011.

It's incredible. And I wanna go into you planning to open back in this day where there weren't a lot of DPCs and people didn't even know the term d p c. When you say you prepared, what did that actually look like for you? Because there wasn't, you know, like the bagel, you know, checklist, how to open your dpc.


Oh my goodness. No, there li there was literally nothing. I mean, uh, again, my, my, my memory might be a little cloudy on this, but I, I think there was literally only a handful of mentions of quote, direct primary care on the internet. When I launched my website in 2010 or 2011, there was a couple news articles, but really there wasn't even a, there was no brand, I'm not even sure, uh, you know, that, that legally there, there had been mention of direct primary care in the Affordable Care Act.


But like in a public sphere, in a business sphere, it really wasn't a thing. And so really there wasn't a lot of resources. So I read a lot of stuff just about entrepreneurism, um, small business resources and talked to a handful of, of doctors at that time. But really we were, you know, especially in those early days, really making, making it up.


I know we're still doing that to a degree, but there was no recipe. There was no checklist, there was no nothing. So I think just learning to be a good small business owner and entrepreneur back then was the most important thing. And I still think it is. You know, I think that's, you know, although I'm, it's amazing that so many resources exist now.


I, I think we should be still aware that being a good entrepreneur and good business owner is required. It's not like you can just get a 15 point checklist and be a business owner. So, um, but yeah, back then it was like there was no recipe. There was no one really to look at and say, oh, I know this is gonna work.


Cuz we were all very, very new. And that's a nice playoff of your name. Pretty good. Um, so when you talked about how for financial reasons you were working, moonlighting shifts doing er, it was great also that you were doing that for your experience going into a private practice where you were a private doctor without, you know, having years in fee-for-service before jumping out into your own practice.


So, can you speak to this fear that some people have about, well, I can't open after residency because I, I don't know enough to be able to practice on my own.


Yeah, no, I mean, residency prepares you to a degree in terms of your, your knowledge base, but it's, it doesn't feel real in many cases cuz you know, you have, especially if you're in a bigger.

Hospital, you know, academic setting. Like I, I finished my residency in, so I, I really learned how to be a doctor probably in the er, um, my third year of residency cuz I, I, I like money and so I, I worked a lot my third year of residency and moonlighting cuz I had the opportunity to. So I really do think that was crucial in helping me.


I was gonna do it one way or the other cuz I'm unemployable. But I really do think it made me more comfortable because being in the er in a rural setting, which is where I, where I worked, there is no resources. I mean, you are on your own. Even if there are other doctors in town who are on call, they don't answer their phone.


So you quickly learn to be comfortable on your own in that setting. And, and I think in D P C you have to a little bit as well cuz you're not gonna have an army full of, uh, people helping you most of the time in a D P C practice, especially if you're opening your own. So, no, I think that was super important and allowed me to care for people.


At a higher level of illness or acuity and allowed me to be comfortable with that, and that's the huge value of D P C. If I, if I practice medicine just like people in a traditional fee for service model, then it wouldn't be as valuable. So I, I don't tell people I'm an emergency room or can provide this same level of service, but I do think I'm able to be more comfortable caring for things that I wouldn't have been able to otherwise.


And I'll just put in a plug here, especially for family practice doctors or people who are applying for family medicine residency, that's a reason to look for an unopposed program. And for those listeners who might not be aware, there are opposed and unopposed programs. And the unopposed basically means that the family medicine residency is the only one in the hospital.


And so you pretty much do all the things. And so, especially if you're thinking about how could I develop confidence to do D P C, that's one way to strategize about it and go to a residency where it's all you as a family practice doctor. So with that, you have this training and this confidence underneath your wings, and then you open.


And in Lawrence, because D P C was not a thing really back then, what was the adoption like in your community? Did you know on day one you have a hundred people? You know, I, I got in practice, I got lucky in some respects. I got, you know, a couple news stories, I think like the week that I opened or the week before.


So, Mean, I had, I think a lot of buzz even in the first couple months and I think the first month I signed up like 20 or 30 patients based on a news story. Now I'm not sure everyone really understood what I was doing. So I say I had, you know, 30 patients in my first month. I think, you know, half of 'em within a month quit cuz they were like, wait, I have to pay every month?


And I'm like, yes, it says that. You know? So I thought, you know, I had an amazing start, but you know, it really took me a year or two I think to really like even come close to breaking even financially. So I had, you know, some early nice media success, social media. I was very active on social media back then.


Before I hated it. Well, I probably even did hate it, but it was more of a necessity. So yeah, I mean in terms of direct primary care, there was no brand. So I used the phrase a lot when I was talking on social media more broadly to people interested in healthcare topics. But locally, like, I'm not even sure my patients could have told you I was D P C or direct primary care.


So I used the term on my website, but you know, I used the term membership medicine or you know, membership based practice a lot cuz people understood that. Whereas D P C wasn't really defined. So even today, I'm, I'm not sure that my patients have this strong connection to the brand or the phrase d p c.


That's kind of like what I talk about with my doctor friends, and they all know what that is now, but my patients just know us as new care or doctor new or whatever, and they know they pay a membership fee.


I love it. And as you, you know, had those 2030 people join the practice and then you grew from there, did you get a consistent increase in patient members or did you have an ebb and flow?

Oh yeah, yeah. Ebb and flow. Still to this day, you know, I'm, I'm 11 years in and there's ebbs and flows and sometimes it might be something I did, but sometimes it's just random, you know? Uh, I mean, the pandemic has definitely like thrown a lot of stuff in there. But, uh, yeah, I mean, even in the first six or eight years when I was pretty much close to my own personal capacity, you know, we would get some months, we'd get, you know, four signups.


Another months we'd get 15 or 20, and I wasn't marketing more heavily those months. There may have been some seasonality to that, but. You know, I think month to month it can be hard to judge things, whereas you can start looking, you know, quarter to quarter, year to year, it starts making a little more sense.


But even then, I'm not sure. And when you mentioned the pandemic, because you were clearly open before, during, and now after the pandemic has quote unquote ended when it comes to D P C, and no matter what your under your patients understood it to be, they knew that it was care with Dr. Ryan Newel. Mm-hmm.


How did you view D P C in terms of D P C is robust because of, you know, X, Y, Z examples, or D P C was so valuable to your patients because of, you know, this Yeah. This type of evidence? Yeah. I mean, I think from a day to day, uh, standpoint, it really wasn't. As much of a learning curve for us. Um, I know that the entire healthcare system was in disarray trying to figure out how to do quote virtual care or quote telemedicine.


But to us, that's what we've always done, you know, because even, you know, day one, I would always start with a phone call, text message, or email, and then escalate it to an office visit if needed. So we've by default been virtual based or whatever you want to call it. So really we didn't have anything to really learn or work out.


And so our, for our patients, nothing really changed. You know, they, they text message and emailed us with a concern or problem, and if I could solve it that way, I did. And so our clinic never had to really deal with that growing pain of theory. How do we care for people when they can't come into the office?


So, yeah, so I think for both us and the patients, that was nice. And from a business standpoint, because we're membership supported, I didn't really have to worry about, you know, number of office visits per day. I got paid the same, you know, three months into the pandemic. My revenue was pretty much the same as it was.


You know, three months before the pandemic began, and I know, especially my primary care friends who were in traditional practices, I mean, they were. They were on the verge of bankruptcy after three to six months because their revenues just went down so much. So yeah, I mean it was, the pandemic was definitely not to say that the pandemic wasn't challenging, you know, we were trying to figure out, like everyone had to get testing supplies and p p E and all the other stuff that other doctors were dealing with.


But from a business, um, standpoint, it was easier for us, I think, to adapt. And

in terms of the members at your practice, how many members are individual members or family members versus, I don't those sta off the top of my head, but I would say, you know, we have kind of two key demographics, I would say we have families with, with children, you know, uh, under, under 25, we have a lot of like larger families or a better deal for larger families.


And then we have people who I would call, or their pre-Medicare patients. So between, you know, 50 and 64. Who have a lot of chronic illnesses. So I think that those two demographics make up probably 80% of our patients, if I can categorize them. But we really run the gamut. We, we are more uninsured, I think, as a percentage than most DPCs, but I know a lot of DPCs care for uninsured.


Or quote underinsured patients. So, yeah, so I, I think we kind of run the gamut of people, and I think most of our uninsured people are self-employed, small business owners or artists. I live in a college town, so there's a lot of starving artists and musicians. So I think that those, those kind of describe my practice demographics as well as I can.


That's awesome. And you know, I, I'd love if you could touch on your advocacy as well as your participation in like r i p medical debt and just how you talk to people about, like, D P C is not for the rich, it's not exclusively for the rich, I should say. Yeah, I mean, I, I, I've been beating that drum since 2011, 2012, trying to clear up that confusion if I'm being nice to the critics about this.


And, and I think there are some people who are just literally confused. They've never heard of D B C, and then they conflate it with concierge and then the, you know, the connotations are there. So I, I think. Some people are con, like literally confused or just unaware. And so I've spent years, long time ago writing about that and talking about that, about my patients and my practice and, and helping, you know, people do some research on this, uh, these topics.


And so, you know, I, I think that that's been, you know, the evidence that that isn't the case has been clear since 20 16, 20 18, but yet to this day, I still hear people say it. And so some of the people, again, are just completely unaware of D P C. Some people, even despite seeing the evidence, still say it for whatever reasons, you know, I can, I can speculate as to why they want to continue to say that, but I think people in the DPC world know that that's not the case.


And I don't absolutely, I increasingly am. I guess unconcerned that there's people trying to spread misinformation because we can't stop them. I mean, so as long as we continue to grow our practices and movement, I don't think our patients care about this. I think this is like, you know, people in academia, you know, turning their nose up at something that they don't understand and no one's paying attention except for us.


Recently there was an article that was written by Hunter Schultz, where he was talking about venture capital and direct primary care and where the two meet in the road. And then, you know, going forward, what can happen if the two interact. And so recently we are very much aware in the D P C space that as Dr. Doug Freo calls, uh, one medical A D P C and name only when Venture Capital comes on board. Do you see that being successful as, as Hunter Schultz pointed out in his article that he, you know, from what he was presenting, that that's the very skeptical thing to see where venture capital can, can continue to honor the autonomy that we have as physicians, as well as the autonomy that our patients need to be able to access.


Transparent pricing and transparency without somebody dictating who can, you know, who can have what? I haven't read the article, but so I, I can't really comment on that. But on the, on the topic, I mean, D P C for the most part, I know there's a few examples of something the contrary, but for the most part, the D p C movement and the bulk of the practices and patients served by it are made up of really tiny, small businesses like mine.


And so I think in that setting, it, venture capitalists have never offered me money, nor do I think they're gonna offer any other business. A small business whose revenues are, are probably well under a million dollars venture, you know, money or, or investment because it doesn't really make sense. Uh, I mean, venture capitalists, you know, early stage investors are looking for a 10 x or 50 x return on their money, and that's.


I would say literally impossible at a local small practice level. So in some respects I'm like, I, it doesn't matter to us. Like I, I don't know anyone who's legitimately trying to do that with their practice. I think most of us, you know, even if we're trying to conquer our universe, it's a pretty small universe.


I know that companies serving D p C practice need investors, right? And so there are some large companies, whether they be, you know, software or some other support service that are serving, you know, hundreds or thousands, like, yeah, I mean, it makes sense for them to get investors. And I don't view that as a threat to the d p C movements anymore than, you know, purchasing medications from a giant corporation to sell to my patients at wholesale prices as a threat to the movement.


I do think it gets a little bit, there's at least some potential moral hazards if, if someone is trying to start a, you know, a. Huge corporate version of D P C, meaning that there's like one company and they own hundreds or thousands of locations. One medical, uh, just to comment on that is not D P C.


They're not only, not D P C and name only, they're literally just not, I mean, they, they bill insurance plans. They contract with private insurance plans. So I don't even, like, I know in the media sometimes they label 'em that, which is very confusing cuz one medical's never used the term. I don't even know how that got started, to be honest.


So they're, they're an insurance-based practice that charges an extra fee, um, which is more similar to what concierge doctors or MD V i p, you know, which is one brand of, of concierge. So I don't even give them the credit of calling 'em A D P C A name only cuz they don't use the term. So, yeah, I, I mean I, I, I get people's concerns because I am a fiercely independent doctor and business owner.


But at the same time, like I don't think investors are able to like disrupt these individual practices cuz they're not gonna offer us money. I'm not gonna give them a 10 x or a hundred x return on their investments.


You could on Band-Aids, like I, I fill my, my cart with extra band-aids when I, uh, need to fill up my, my cart to get free shipping.


But no, I, I'm really glad you touched on what you did because at the D P C summit, you know, last weekend, it was interesting to hear some people talk about like, well, maybe I should join a place like One Medical or a place like M B D V V I P versus opening A D P C or joining A D P C. So it's interesting that, you know, where you started there, D P C wasn't a thing and then now people are having that type of, of thought to be Well those, yeah, I mean those tho even those two companies, you know, which I don't want to belabor, give them too much airtime.


I mean some of those are like one Medical is an employer, right. So being an employed doctor in a big company is just a totally different thing. And I, there might be opportunities for, you know, there, there are increasingly opportunities for doctors to be employed by D P C practice and most of 'em are pretty small businesses and practices.


So, yeah, I mean, I think you, you get down to this, you know, and I've heard this since 2012, 2014 even. We were, you know, growing back then, I was happy and I think when we officially had a hundred D p C practices in Nationwide and what I heard back then was, well this is cool, but it's never gonna scale. And then we got to 500 and people said, this is cool, but it'll never scale.


Then we got to a thousand, heard the same thing. Now we're at, what, 2000, I don't even know what the number, but it's cool, but it'll never scale. And so I don't even know what people mean by that. Frankly, I, I don't know if they think we're gonna go from a thousand to the majority of practices overnight.


Like I don't, I don't know what people mean by that, but I've been hearing that since there was 10 practices or a hundred practices at DBC will never scale. And yet there's more and more and more and more of us. So you, maybe that's not scaling, maybe that's like gremlins or something. We got wet and spawned each other off.


I'm not sure. Again, I'm old. I know the young people won't get a gremlins reference, but to me that is scaling. It's, it's a, it's an organic movement of a bunch of independent businesses and maybe, maybe venture capital don't like that, right? Cuz how can you make money on a cottage industry? Right? You can only make money if it's a, a one collective that all the money goes into.


So investors probably aren't interested in a cottage industry, but. That doesn't mean there's not gonna be more cottages and there are more cottages. And so I, I don't know like what that means, you know, is, is D P C gonna be, you know, 50% of the primary care market? Probably not. And that's okay cuz I don't think anyone has a specific goal there.


I certainly don't, but I don't think that means really much if we continue to have practices open and be successful.


And even like you spoke about your patients, like they might not know exactly like what the legal definition of direct primary care is, and to them, they just know that they can pick up the phone and get ahold of you.


Yeah. And that's what makes the difference and that's why, you know, if you're thinking about D P C and you're on the fence about like, what is D P C, can D p C survive? It's like, You have been open since 2011. That is flipping amazing. So, you know, I, I put that out there, especially for people who, they got some enthusiasm, but they might have some fears, uh, making the, the leap into D P C after attending D P C summit.


So one of the things I love about you, and I remember this from the 2019 summit talk that you gave in Chicago. Uh, you had a picture of like your snazzy hat and you're in your white coat in front of the, the porch. It was super awesome. I love that picture. But you do home visits and like, you know, that's the thing that you can do cuz it's your practice and you can do whatever the heck you want.


Yeah. So can you talk about how did you start incorporating home visits and was that part of your training as you just continued it in your own practice?


Yeah, I didn't really, I think the closest I came to like home visits was, uh, visiting in residency was probably doing like assisted living or people who were in a. Like a retirement community. We had a few patients that we, we would do a few of those. I think in residency we did a handful. But no, I didn't really get much training on that. But you know, I mean, I think that in someone deciding how to form their practice, if that's something they think is valuable and it's something they're comfortable doing, like you can do it.


I mean, that's the cool thing about D P C is, you know, we, we say it's this model of movement, but it's, it ultimately comes down to a lot of decisions for the doctor and what they want do. And so, you know, not all d p C practices do that. I do them, I don't do them frequently. I don't want to drive to someone's, you know, house who just has a sore throat.


So it's not a convenience thing. It's more of like a need thing. So if I have someone who's, you know, post-op or you know, a newborn baby or, or someone who's truly home bound, then, then we do those. But I don't even do a ton of 'em. But I know that my patients know that that is an option if it's needed.


But you know, you have to use judgment in, in that in terms of whether you're comfortable to do it. So I've had many doctors say like, I'm just not comfortable. I'm like, well, don't do it then. It's like, it's not gonna make or break you. I totally agree. And I've had, I've had to tell patients who requested 'em.


I'm not comfortable. You know, like, I mean it, so we all, we all have to use discretion, same as we do a procedure, same as we do anything else. So I don't want people to think like you have to do house calls to do dbc, but it is great marketing if you do them. I love it. And even if you do like one a year, it is great marketing.


That's awesome. And yeah, I, I, you know, I think about, there was a, a person in town whose spouse needed a letter, basically signed a form filled out for the VA to extend his benefits to his spouse. And there was no doctor who would do a home visit and they don't have a primary who in Viver service would go to their house and fill out the papers.


And the spouse was unable to physically get to, oh my gosh. A doctor to, to have the papers filled out. And so like that in, you know, I get into the one-off services, but when I talk to people about, You know, they ask me, do you offer one-off services? I do. Especially for things like that where it's like, sure I have availability.


Oh, a lot of it. Because most of my care is, you know, virtual first and then patients mm-hmm. Are seen in person if I have to. But when you think about, you know, autonomy, I am so glad that you mentioned like, you know, if you're comfortable with it, because we just had a whole talk on boundaries at the DBC summit.


Sure. And that is absolutely something to, you know, keep you safe. And that safety is not just physical safety, but that physical, that safety also extends to Yeah. You know, mental safety when you're, yeah. Stressing about like, oh, can I do this? I don't know if I've done this enough times to be able to do it on my own, blah, blah, blah, blah.


You, you have to listen to that voice before you, you do anything in medicine. And so I think that that's super important. Sure. Yep. And when you have done home visits, because again you've been practiced for a long time, do you have any favorite home visit bag hacks for those people who are interested in home visits?


You know, it's funny, so I ha I have like, my logo is literally a doctor's bag and so I feel bad I don't do more house calls cuz it's literally my logo. But I think it's such a cool nod to doctors of a, you know, different generation. But yeah, I mean I have like an empty black bag. And it sets in the corner of my office.


And so I, I, you know, I'm not usually gonna do more than one house call at a time, so I usually kind of know what I'm getting into and I'll throw whatever supplies and stuff and equipment I need in the bag. So, yeah, I don't know. I mean, it just depends on the circumstance. Like, you know, if it's like a newborn exam, you know, I, I sometimes I'll ask him, do you have a scale?


If so, what type? If not, I'll throw my scale in there, but I basically bring whatever I know is needed and, you know, maybe a few extra little things that may come up. But it's usually a pretty simple thing. Stethoscope and a light will get done. Most of what I need. I loved, uh, when we were at Dr. Esther Cat's talk about at your cervix and just women's health.


I didn't see that one, but I love the name of that. I'm glad I didn't see it cuz I love the title so much. It, it, it is awesome. And her story was that she got it off. She was inspired because of a patient giving her a mug that said at your cervix. And so, but I loved how Dr. Jeff Davenport was saying, you know, little hacks that he had.


Like, you know, if he could not reach the cervix, one tool that he had was like a ringed forcep to basically be the extender for the tool or Q-tip that he needed for the Sure. The cervix. So, you know, it's, it's pretty cool. But yeah, it definitely, you know, if you are wanting to do home visits and you talk to people like yourself and myself who do home visits Yeah.


You know, ask that question. Like, what do you do in this situation? Like, I. Hashtag you can use a Q-tip for a pap smear if you didn't, if you forgot your Yeah. Your, your bright cone bristle. I have, well, I, to clarify, I've never, I've never done a pelvic exam or pap smear at a house call that, that would be a little bit challenging for sure.


So, again, boundaries. But, uh, no, I think it's, I think it's cool. Like I've seen so many, um, innovative things come out of the D P C movement and some doctors might look at it and think, man, those people are just, you know, cowboy wackos. But I think when you mo remove yourself from kind of a system, you just think more creatively.


And there's so many cool things, whether they procedures or techniques that I aren't, aren't necessarily, they're not invented in the DP C movement, but there's these like little cool things that like I didn't hear about in medical school or training and then, you know, I learned about it from someone in D B C.


I'm like, man, that's awesome. That should be the standard of care for whatever that is. You know, so whether it's like a new procedure or a different way to do a procedure. And so I think for whatever reason, because D P C maybe ha, we have more time. Or because we're more open-minded that we kind of discover these things and share them.


And so that's one of the coolest things clinically is like I've heard of, you know, some cowboy tricks that I'm like, man, that is awesome. I wish they would've teach that in residency, but I didn't learn about it because, you know, whatever reason, I don't know, maybe it just wasn't in the textbook or whatever.


Absolutely. And you know, I just, I came from a point of care ultrasound class in, uh, Portland a couple weeks ago, and I heard crazy things like, don't put tegaderm on your, your ultrasound prob because it'll ruin it. And again, there's, there's gonna be people who disagree with this, but I will say that the, the instructors were like, Well, I use Take it room every day and I'm still rolling.


So it's pretty, it's pretty okay. Yeah, yeah, yeah. I love it because, I mean, you're right, when we, when we have the time, I feel like we can, we can think about things differently. Like, I mean, I've had to do so many different types of procedures in people's homes because I was exclusively home visit and telemedicine based my first year.


And so like, there's ways to, you know, maintain standard of care, but do things so it works for your patient, it works for you and you're not, you know, putting anybody in bankruptcy and you're not spending a ton of money to, to do the things that you need to do. So I think that's, I encourage people to ask others how they do home visits if they're interested.


And let me ask you now, going from home visits to your brick and mortar space, you have Ashley and then you also have Jessica. Yeah, yeah. You also have Jessica. So when you opened, it was just you, um, literally just me. I didn't even have a, a nurse. Um, I had, I had someone who would come in a couple days a week, but it was literally just me, cuz I didn't have any money.


To pay anyone. I was working at the ER to pay my rents. So you're, you're much smarter than me. See, the younger generation gets smarter and decides to start with just a house call virtual only. But I thought I needed a brick and mortar place cuz I'm like, I'm crazy enough. If I don't have a brick and mortar place, then no one's gonna take me serious.


And I, I don't know if that's true or not, but that's what I decided. So yeah, I didn't have any staff, uh, full-time in the first year. So I was doing, you know, pretty much everything, all the admin, all the nursing type stuff. And then, you know, I hired a nurse part-time that, that came in, you know, I think 10 or 20 hours a week.


But I was, you know, there a lot, um, by myself. And so, you know, as I grew I was able to pay, you know, a nurse. Uh, and over the years I've had I think three full-time nurses in 11 years. And then probably five or six years ago I hired a nurse practitioner cuz I'd been at my, you know, kind of. You know, capacity for a while and wanted to dedicate more time to doing other, other things.


And so yeah, still to this day, you know, 11 years in, I have one full-time nurse. She serves so many roles, you know, the office manager in some respects and does our supplies and a lot of our billing stuff. Uh, just awesome and does pretty much everything. I always joke that I just like show up occasionally, uh, and let Ashley do everything and I just signed paperwork.


That's all I really do at this point. Which is your goal as a doctor, right? I'm worthless except for my signature. And then I said five or six years ago, I hired a nurse practitioner, uh, Jessica, which is great. She had done some, uh, covering for me when I was on vacation stuff because when I was solo practice, I wanted to have someone available, you know, at least for part of the week for my patients in case they needed something.


So Jessica had worked for like two years, I think about a year or two when I was on vacation. And just everyone really liked her and was awesome and wasn't planning on like hiring her full time as a provider and having her own panel, but. She was just great. And I know there's a lot of debate about the nurse practitioner physician thing there, but uh, she just was so great and the more I got to know her, I was super comfortable with her, you know, coming on board.


And so now we can kind of share vacation time. So we, we keep our own panels though, so I have my panel and you know, if it's a, if I'm here not on vacation and I take care of everything and she takes care of her patients. So, you know, we don't really share patients in that way. Um, and I think that for us has worked out really great.


Awesome. And let me ask you there, when you opened, because you were a solo doc at the time, and now you have three people including yourself at, at the practice. Mm-hmm. Have you moved or have you always been in the space? Yeah, I moved one time. Yeah. So my first lease I think was four years and I think about four and a half or five years I moved into a new space cause we just need a little bit more space.


When I brought on Jessica and I wanted to expand in some other, you know, wellness, fitness services and stuff. So I, and I wanted to be closer to my house, so I found a, a new space that was closer to my house. And so, yeah, I've been here since. I think the sixth, fifth, or sixth year of practice? I think so I've been here, yeah, about five or six years now.


And do you least as of today or do you own I did, yeah, I did. I, I really wanted to own, I think from a business standpoint, it probably makes more sense, but it just depends on your community and like what's available. And so, yeah, I, I really didn't have many opportunities that I saw were worthwhile in terms of an investment.


So I would almost had to build, buy land and build a building and wasn't quite willing to do that. So, yeah, I, I'm leasing right now and, but it's, you know, half a mile from my house. So I walk to work most days when I'm not being lazy and I just couldn't pass up that opportunity. Well, you

can't be lazy because the whole summit, you're like, where's Ryan?


Oh, he's biking or he's on stage. So that was, no, that's cause I'm, I'm, I'm by nature an introvert and I need a lot of alone time, so I have to get away and it's hard for, it's hard for, uh, people to find me if I'm on a bike somewhere in Minneapolis.


Oh man. I love it. Let me ask you, because I, I, I think back to Dr. Delicia Haynes when she shared about how she has experience in interior design, and one of the things that she wished she had even more and more of all the time is space for storage. So when you opened and well, when you moved to your new space, were there certain things where you're like, I must have these particular things in addition to just more physical space.


Yeah, you know, honestly, I, in retrospect, I've probably always had too much space. In fact, I probably have too much space now in terms of just, you know, cuz storage is, is, you know, stuff that you're not gonna access that often. So I probably, in both settings have had almost too much space. I mean, it depends on the day, but no, I, I've never felt like I didn't have enough space.

But yeah, I, I think. You know, designing your own clinic space is really fun. Uh, cuz it's not something that most doctors get to do, you know, they just show up to work and it is what it is. And so just your, your kind of ability to put your own personal touch and flare and kind of your references in there.


I think it's super cool and, and it reflects you as a person and your, you know, identity. And so, you know, and that's gonna take different forms. You know, I'm kind of more minimalist, modern, whatever you wanna say. But, you know, I have a doctor friends who are exact opposite. Their communities are exact opposite than that.


And so, you know, they kind of have a country theme or whatever, and, and it, they both work. So I think, I think our physical space can be these cool reflections of who we are. And so you don't almost ever see that in a traditional practice. They have like the standard clinic wallpaper, you know, that does the same somehow across all of America.


So I think D P C can be much more creative and artistic than that. My favorite, and I'm getting very facetious here, is the stick on carpet tiles where they've moved, uh, so that you can see the little gaps. And those are not important to address or fix or care about. Um, yeah, but I would always comment like, well, this looks like you don't care about the clinic, cuz it's really hard to, uh, I, uh, I digress, but that's my, my facetious comment about fee for service clinics.


They're my favorite. Yeah. So when it comes to Ashley and Jessica and yourself, even though like you and Jessica have separate panels mm-hmm. When it comes to like, moments in time, like, you know, the pandemic or when it comes to, like, if kids are coming in for sports physicals, how do you guys at times collaborate in your practice to Oh yeah, yeah.


To like, optimize workflows or, or get things done quickly. Yeah, I mean, it depends how busy we are, you know, at times. But we, you know, by design aren't, aren't too busy, um, most days. But yeah, I mean I think, I think I, I've always tried to foster, you know, even though we're really tiny, it sounds funny to say any of this when you're so tiny, but you know, we always have students here.


I mean, I have medical students most of the time and I have pharmacy students sometimes. So it, we've always just tried to foster like a learning environment. And I know that sounds cheesy, cliche, whatever, but like, we're always just talking about our patients and something interesting or something challenging.


So it's kind of just like this open dialogue. And so, you know, for us it's just kind of part of the day, you know, so we call it like collaboration, but it's not like, it's not like my mentor in residency where I had to go set and present the case to them, you know? So I think my nurse sometimes is, is interested in this stuff as I am, you know?


And so, you know, one of my nurses ended up going to medical school, another one went to law school. Yeah. So I think we've always just done that here. And so when you have more time with each patient, more downtime, like, I think it's just natural to kind of learn more about. Something, right? Like we're one of the new, um, medications for atopic conditions.


Do Dupixent, Dupixent, I can't remember the name of it. Anyway, we haven't really used that a lot, but like we have a lot of patients who still struggle. And so we, we've had a couple patients start on that recently and Jessica has made severe eczema that just can't be managed the other way.


So, you know, they did see a dermatologist at one point and didn't really stick with the medicine.

So we figured out how to get done the medicine for free and that's like a stupid expensive medicine, but they're uninsured. So we got into this like $2,000 a month medicine and I was like, I've heard of this medicine, but I don't really know. So we just sit down and start reading about it and it's like, oh, maybe it's actually lower risk of side effects.


And you know, you know, we look up the monitoring parameters and stuff, so that's kind of like, like it's always just us trying to learn more and sometimes like I know more about something and sometimes maybe my nurse knows something you know about something that I don't know about. And so that's kind of how we just approach it.


It's just a natural learning environment and hopefully we all get smarter with time. That's a good goal. That's definitely a good goal when it comes to the fact that you've had multiple nurses join your practice mm-hmm. And then, you know, branch off into mm-hmm. Into other, yeah. Life. How do you hire, how do you hire people at your practice?


I wish I could give some magic here. I've just gotten lucky, to be honest. You know, when I hire nurses, you know, I didn't get like a million applicants, so I didn't have a ton to sort through. But really for me, like when I was in that process, like one or two every time I had to hire someone stood out based upon the initial email or their resume or whatever.


And so I've just gotten really lucky. You know, I, I know other doctors if this is a big struggle. This is not unique to D P C, but being an employer, oftentimes the hardest part is hiring reliable people. And so I've just gotten really lucky, and we've always had good employees who showed up and, you know, um, were really, really smart and caring.


You know, the worst thing is when they leave, but you know, that comes with the territory, right? If you find someone really good, there's a chance. They're going to leave. So, you know, that's, that's challenging, but that's true of every business and business owner. You know, uh, as you find someone who's really good and reliable, and then you have to eventually replace them.


And for the transitions that you've experienced at new care, how have you documented your workflow so that a new person can start without you having to retrain everybody? Like I said, I got good people. They trained each other. Like, I mean, I, I really didn't, uh, I That sounds strange, but you know, I mean, obviously when you hire a new person, there's some things they don't know about you and, and things you prefer.


But my, my nurses have always been really good. And then, you know, they, they gave us fair warning when they were gonna leave and they started writing stuff down and passive the next nurse. And then they worked side by side for a few weeks or few months. And by the time the other one left officially, you know, and some of 'em even kind of like worked a little bit after they left just to kind of touch base.


And so they, you know, they took their job, I think, serious enough that they didn't want to just drop the ball. But I, again, I just gotten lucky. I. That's probably not something you can always guarantee. So I actually probably haven't written down that much. Uh, the nurses have like a, something they've written up and they share with each other.


And then, you know, we've had other like part-time nurses or PRN nurses and we have another part-time PRN nurse right now. So you have to kind of, people aren't here here that often we have like some guidebooks and manuals, but I'm sure you made a lot of people jealous, uh, in terms of the, the luck you've had with staffing, but also the fact that, you know, they're helping each other maintain the quality of care at your practice without gaps.


And I think about it, I think about, um, Dr. Nick Thompson and Dr. Brandon Alman who are in Kansas in another different pardon in Wichita, they were talking about how one of their nurses is working remotely. Um, and so just something to think about if you have a staff member who's moving and they're willing to help, you know, train the next person.


Oh, we do that still. Yeah. Yeah, that's great. And sometimes it's like really challenging just with everyone's, you know, lives and work schedules and so. We've done that, like when both nurses have been unavailable and like, I'm like, okay, can you, you know, wherever you're at, do you have access to the internet?


Like, yeah. I'm like, okay, you can just log on for like one hour in the morning, one hour in the afternoon, check emails, make sure we're not getting behind on those and voicemails. And so yeah, they're, they're self-starters. So I, that's my, you know, biggest piece of advice is find people who are self-motivated and self-starters and, you know, not that you don't need to have some direction, but if, you know, it's like my children, I tell them like at some age, like, you don't need me to give you a seven point process.


If I say clean your room, clean your damn room. Like if I need to give you a 15 point checklist that you know, past a certain age, like that's a problem. So

yeah. Self-starters. That's a, that's a good, good takeaway. I love it. So you had us all, like, I suspect that everybody was tearful at the D P C summit.


You did? Oh, oh my, my presentation. Crazy. That's yes. For those who didn't intend, you're, they're gonna be like, what? Why didn't you talk on fitness? Why is these people crying? Yeah.

So you did a, a talk in a, in the 3 0 1, so it wasn't recorded, but the, the slides are available. But it was just incredible because the opening, you know, commercial video that you showed was really getting at the heart of why we're all doing this.


And in, in that particular lecture, you were talking about fitness, and you weren't talking about lifespan, but you were talking about health span. And so mm-hmm. You have opened Fitness DX as mm-hmm. You know, as an extension of new care. Can you start us off by telling us what is Fitness dx? Yeah. And how does it differ from new care?


Yeah, so from the beginning I have always in my practice, and I think in my training and, and maybe even going back to when I was younger, you know, recognized that lifestyle, which I actually hate the term lifestyle, but you know, I, I say it with, with quotations. So that lifestyle, uh, is important. And I think all doctors know this, especially as you go throughout your training and, and see the manifestations of people abusing themselves with, you know, tobacco or alcohol or whatever.


And, and obviously poor diets and the sedentary and all this stuff, we, we know this, I think, and so I, I've always emphasized, you know, I think most people in family medicine, that's, that's probably was probably the one specialty that actually emphasizes it. I, I know other specialties, you know, no offense to them, but it's, it's a tiny percentage of, of what they do.


You know, they just wait for people to get terrible things and then fix them. And I, so I think, I think by the nature of being a family doctor, we get trained in that, but I don't think we actually understand it very well. So I will say from the first day, like I've emphasized prevention and quote wellness, lifestyle, but you know, as the years went on, I had become increasingly convinced that then unless people do better with that stuff, my powers are just very limited.


And I think all family doctors feel that way. That kind of fatalist perspective is, is natural because people are coming to us and even if they come to us religiously every year to get their quote checkup, their lifestyle, their inactivity, their smoking, whatever is so terrible that there's nothing we can do to avoid that kind of cliff.


Well, cliff would be the, the better outcome for many people. Again, I'm a fatalist, so that slow, miserable decline that we see coming. Right. You know, we can see it coming. We try to warn them, but it's. You know, it seems like we can't, you know, keep them from that sad fate and that sad fate is, is not a quick death.


Like I said, it's, it's that suffering and that misery that happens in the last 10 to 20 years of so many people's lives, you know, that end up, you know, losing their independence and their autonomy and they're frankly unhappy. And I would be too. And so, you know, despite all of the miraculous things we can do in medicine, testing, screening, medications, the reality is, is most things we do in medicine do not really improve that health span, which is the number of years you live at a functional high level, we might be able to extend life a little bit.


You know, I, I know life expectancy is, is viewed as this, like, you know, oh, this country's good and this country's bad because they live 79 and they live 81. And I'm like, well, I mean, to me that's always kind of fell short of defining our goals, right? So I think that's just been my, like increasing experience as a doctor.


Is it. I, I feel, feel like if we don't do better educating people or helping people with these topics that we're maybe extending their life, but kind of for a miserable existence. And so, you know, you can take any part of that you want, but to me, I think it's pretty clear that activity or physical fitness is the most important of all of them.


The more research you read on this, it, it becomes very clear and apparent. So I know there's probably more people in the primary care world or in the D p C world who are super fixated on nutrition, you know, and they fly some flag of whatever, you know, brands. I'll try not to offend people in this talk. I did, I'm sure in the, in the summit talk.


But, um, you know, and it's not that I, I don't view those things as important and clearly the standard American diet is, is terrible. But for me, I just, I kind of came to the conclusion that without physical activity and improvements there, like our society and culture is doomed. I think we will continue to suffer the same sad fates.


So yeah, so, so that's kind of wh where my headspace was at probably four or five, six years into practice. And so, you know, I, I continued to explore those topics, you know, cuz the reality is, is even though I'm a pretty active person and ran college track and field and, and tried to stay in safe my shelf, I, I probably wasn't that good a shape cuz being a small business owner, that's, that's hard.


But just started like exploring that, like, just started reading a lot more and, and going down so many rabbit holes and realizing that, man, I didn't get any real education on these topics. And the science is super fascinating with a lot of this stuff. And so just kind of like in my own personal journey with that and helping some patients through with it.


And then, you know, I have a few patients who are like actually competitive, you know, athletes trying to help them, you know, accomplish their goals, which is super fun and, and just decided that, you know, I need to do this better. I need to kind of create a service for people that goes beyond what you would call traditional.


Prevention, but it's very time consuming and, and can be expensive. Some of it can be. And so I decided, you know, probably four or five years ago that I wanted to kind of launch this fitness testing, counseling service. And you know, I kind of started gearing up to do that and bought some equipment and then, you know, then the pandemic happened.


So I kinda had this brand, this cool idea and then, you know, 2000, end of 2019. Is that when the pandemic started? Yeah. And so I kind of just put it in the back burner cuz I'm like, oh no, you know, no one cares about anything except for this one virus. So I continued to do a lot of it kind of in the backgrounds, but then decided I'm gonna really do it like I have to kind of.


I have to create a separate service and brand for it. So I, I launched Fitness DX earlier this year, and it's hoping most of my patients, if not all of them, do it. But, so our, our patients, you know, get a discount for it, but it's open to the public. So we took like one big room in our clinic to put some equipment, some testing equipment and stuff in there.


So, yeah, it's, it's the, the way I tell people is that it's a way to diagnose and monitor your fitness as well as get some really good feedback or exercise prescriptions. You know, there's no silver bullets. You know, it's funny when I describe this to patients, and sometimes doctors, they're like, so you're doing hormones or something?


I'm like, No, so, so it's, it, it's, I'm still trying to navigate like how to present. It's, uh, but I think we have like a really cool, you know, website with the descriptions of the testing, but you know, it's, it's, some of, it's pretty, you know, in-depth scientific stuff. Uh, and I'm trying to figure out how to translate that into, you know, general population.


I love it. And somebody asked during a lecture, what made you decide to carve it out as a separate service versus include it Yeah. With your membership?


Yeah. Um, and time, I mean, so the, the rate limiting step in providing primary care is time as, as everyone knows. So, you know, my fees are super affordable.


Uh, I think our average is, you know, with family discounts and stuff is like near $50 a month. And so some of this fitness testing is, is quite labor and time intensive. And so, you know, depending on what the person's goals are, they might want to do it a lot. And there's no way we could provide the level of testing and, and counseling under this.


So I still emphasize it. So even if people are not doing the fitness testing, I still probably spend half of my time in their yearly preventive visit talking about these things and giving as good a direction as I can to them. And then some like really, I think good emails and stuff about like, here's what you should do.


And then I say, Hey, if you want to dive deeper and get more feedback about your current level of fitness. But, you know, I, I've joked for years, you know, even back at the beginning of my practice said, you know, you have these patients who come in every year for their checkup, right? What's my cholesterol doc compared to last year?


You know, their LDL goes up and down, who knows, sometimes random. And they're trying to use this as like a proxy for how healthy they've been over an entire year. And I've always known that was just a little bit silly, right? And some of these people are like clearly struggling, right? They're 52 years old, they can barely get out of a chair and they're worried about their L D L and, and not to say that LDL is not important over the next 30 years of their life, but like, I'm like, they have like a clear and present problem and you know, they can't walk up a flight of stairs yet.


They were fixed in the ldl. So I've always joked and I have actually. Offered this to many patients. I've only had a couple take me up on this. I say, you know, I don't really think it's gonna be that helpful to check your cholesterol once again, you know, for the 50th time in, you know, 10 years or whatever.


Let's just go walk up this hill right here and see how you do. And they're like, what? And I'm like, well, that would tell me more than checking your l d l yet again. And, oh no, I just wanna see what my cholesterol is doing. You know, like I, I think what patients are desiring from doctors often is they want, like, when they say they want to check up, what they mean is a, do I not have a problem?


Or like, even more so like, like a prediction of the future, right? Like, I think, I think we don't think of it like that, but I think people are like, you know, they wanna go back home and tell their spouse or their family, Hey, I've got my checkup. Everything was fine. And I'm like, that doesn't, you know, it just, it falls so short of understanding human health.


So I've, I've always joked that I would much rather, if you made me pick, I would rather walk some up the hill near my office and see how they look rather than doing their labs or vital signs or anything like that. So, And I have no idea, you know, how c m s would code that and represent, you know, the, the visit of walking with your doctor up a hill, even though there's a code

for, I think that's really, yeah.


If you wanna get really into this, like the, the perverse incentives in our medical system, you know, and the, and the traditional, you know, c P t reimbursement driven system are really the problem. I, I think like, you know, if you, if you watch my presentation or any other, uh, doctor's presentation about this, if you look at what matters in terms of health outcomes, you know, these topics that I'm talking about, someone's cardio, uh, respiratory fitness, their skeletal muscle mass, their strength, um, there's so many other functional measurements.


That are so much better at predicting health outcomes than the things we measure and practice. And it's like, well, why don't we do that? There's no way to code and bill for it. I mean, it's, it's, there's so many things in medicine and I think that about so many things when you, when you look at people in D P C doing things outside the box, I'm like, well, why did they figure, it's not like, no offense, but we're not like geniuses.


We might be average at best doctors, but we discover things because we're not trapped into can I code it as a 99 2 13? And if I can't, then it just doesn't, we don't do that. So, yeah, I've, I've often thought that, that like, we miss so many things that are important because it's not a codeable service. So I don't know.


I mean, and I think if you step back and look at health and public health and, you know, the broader problems that poor American health pose to our economy and our civilization, our culture, like these things matter more than, than many things we do and pay. A lot of money for in medicine. So, you know, bang for your buck.


It's kind of a no-brainer. But again, our medical system, it's just like, well, we have medicine and then we have health, and then health is like this weird thing where you have trainers and stuff, you know, and, and no offense to trainers, but you know, we need to have some recognition that that stuff is. As important as anything a doctor does.


Not that you need a trainer, I'm not endorsing people needing a, a, a personal trainer. But yeah, in terms of health and outcomes, like it's, it's very clear that that stuff matters more than most of the things that doctors do. Well, it makes me think about, you know, we have so many patients, especially in, in primary care, where they come in for their Medicare wellness, physical, and they're so shocked to this day where it's like, wait a minute, this is the visit where you can't touch me or listen to me.


And it's like, yes, that's correct. We're we're, this is the, the talking visit. And then we even had a patient come up to, my husband and I were, when we were walking one day, he's like, well, Dr. Fala, I'm gonna cancel that appointment cuz I think it's bs. And my husband was like, so do I, so I'll see you at your actual visit when you actually have a problem.


So it's, it's pretty crazy that, yeah. You know, when it comes to, again, I love how you use health span versus lifespan. Yeah. And you made a very good point, you know, graphically, you had two pictures up on one of your slides at the top where it was like, I. Here are three people, and they're like, you know, they're older people, gray haired in their jogging suits, like going on a walk with a doc, and then you have the lady who is decrepit in the hospital chair bed.


Yeah. And so it, it's really like, I, I think it's so empowering Yeah. For a direct primary care doctor or direct specialty care doctor to be able to, like, I think about, like Dr. Nicole Harken, she's a freaking cardiologist and she's talking about preventative cardiology. Like we do prevention on such a different level because like you said, we have the time to do it.


Like, I had an hour and a half conversation with a patient today just about prevention and about, you know, horses versus zebras. Let's check and make sure all the lifestyle things are optimized before we go, start going after the, the things that, you know, you could invest lots and lots of money and time on.


But I, I think it's, it's so awesome as a, as a D P C doctor, as a drug specialty care doctor to be able to have that time like you've pointed out. So I love that. Now when it comes to you, you mentioned this how you, you have kids, you have four children, and so I wanted to ask first, where along your d p C journey, did each of your children join you?


Well, yeah, in terms of like how old they are now. So my children, I'll butcher this. God, I hate, you know, when you get this many kids, you actually have to like stop and think about it. So my oldest is 13 and uh, my youngest is six. So yeah, my first child was born in my first and second kids were actually born in residency, uh, the second one right before I started.


And then, uh, the second two were born after I started my practice. So yeah, they're all, they're all pretty pretty bunched up together. And yeah, that, I mean that's, I think no matter what career path you take, having children is a ton of work. So, but being a small business owner and starting a business while having a bunch of small children was very, very stressful.


But again, I mean, I think that's true of no matter what path that would've taken. But yeah, there was a couple years there where it was, it was very, very hard, uh, I think on my wife and on me to be, you know, moonlighting full-time and trying to start a business and being stressed about that. So not for the faint of heart to have four children while starting a crazy business.


Ideas trying out of residency. And as you, you know, went through life, um, with one kid and another kid and then up to four kids, do you have any things that you learned to help keep peace at home in terms of stress levels down or hacks to be able to be present for your kids as you were continuing to dive into or delve into entrepreneurship?


I mean, other, other than contraception. Right. Love it. It took us a while. We were like, wait, you can just not have this happen. Yeah. It took me way too long. I, like, I slept in a lot of medical school lectures and my wife's a pharmacist. She didn't know better, but whatever. Yeah. Um, I don't know. I mean, I'm not one to give advice on, on these things for me.


And I think my wife probably to a lesser degree, like carving out time for ourselves, you know, is super important. So we, we definitely are ranging according to my neighborhood, free range children. And so the more kids you have, the more you believe in such a movement and idea. And so we've tried to let our children be very, very independent, you know, as soon as that was safe and possible.


So I think that really helps. But then, you know, trying to get time for yourself, you know, whether it be totally by yourself, in my case, cuz I'm an introvert, my wife's opposite or together. I think that's super important. So we've always tried to do that and we've, we've tried to not let kids slow us down.


I, I heard so many people, you know, as you know, we had kids, I guess relatively young nowadays. It seems like you have kids before. 30 people. Thank you young. Oh my god. You have kids at 26 that's like super young. I'm like, well my mom had me at. 18 or 19. So I don't know. But yeah, we've al we've always tried to say that we weren't gonna slow down our lives because of our children.


I, I think so many people said that. And we were like, but you can just take kids on a plane. You can take 'em anywhere. So we, like, we continued to travel, we continued to like live our lives. We weren't gonna like put our lives on hold because we had children, because then you, I think you kind of end up presenting them, you know, like, especially if you like travel and doing, you know, fun things.


So we've done some crazy things with our children over the years that most people are like, are you insane? You took your children where? And they're like, I don't know. I mean, we have kids and we wanted to go there, so we just, you know, took 'em. So I think that's my, I guess my best advice is just to keep living your life and continue to be active and continue to travel and, you know, I know that can get expensive, especially with four children.


So that's what we've always said is like, we want a lot of kids, but we don't wanna like, act like we have a lot of kids, if that makes sense. And it's hard to have the best of both worlds, but I think. I think it's


possible. Absolutely. And I think that the fact that, like you said, there's a way different presence of D P C in the nation than there was when you opened.


There's lots and lots of us who have kids and are still practicing. Like, we didn't, we didn't perish because we gave birth, you know, so it's a, sure you can, you can do both. Um, yeah. And obviously di differences here between men and women. I know women that's, that's much more complicated, uh, in terms of, uh, you know, in the, especially the first year or two of, of, uh, of Ed's life.


So, yeah, my, my nurse, nurse practitioner, Jessica had, I think a kid like three or six months after she joined here, and I knew that was gonna happen. And so that obviously was much more difficult for her. You know, I'd just come home and be like, yeah, they eat well today. Okay, good. I'm going to bed. You know, so I, I definitely, as a dad really can't.


Say that anything is hard compared to mom's? Well, I love, you know, I, I think about when you talk about Jessica having a baby while practicing. I think about Dr. Jennifer Allen, how she has the little ones just come to the clinic, like they're quiet. They literally don't fall over. We know when you, when you put them in a place, they stay there.


We have kids that are, we have our own kids here quite often, you know, especially like in the summer when, when school's out and stuff. But my kids, they're elementary school, my two younger ones who are still in elementary school, my practice is almost exactly halfway between my house and the elementary school.


So they literally walk by my clinic and nine times outta 10 they stop by and like, steal our snacks and get a drink and complain that it's hot outside and I have to shoo 'em out the door. But sometimes I'm like, whatever, we'll throw on a movie on, in the, the extra room there. And so I often come in and my nurses give them a bunch of, you know, treats and stuff.


So it's great. I love it. Now, when you talk about one of your, you know, hacks to keep your yourself and your family balanced, is, is respecting time for yourself. I, I wanna go into the idea of burnout because whether it be thinking about how you are present as a parent or how you are present as an owner, how do you look at burnout and how do you look at prevention of burnout when you're a D P C physician?


Yeah, number one, I hate the term because I think it implies that there's something like wrong or weak with the person who's quote burned out. So, so yeah, not, I'm not, I'm not, uh, putting that on you, but because I know that's, that's the term that we use, but I just hate it and I think it, it kind of implies that physicians are not like, resilient enough or tough enough to kind of deal with whatever is required.


And I, I think that's mostly garbage because I think. Most of my friends who got into medical school and like, were really hard workers, were really disciplined and I think we're able to deal with a lot of stress, maybe more than the average person, although, you know, I know everyone has stressful lives.


So I, I think, I think there's two facets to that. I think within the regular medical system outside of dbc, I think there's so many moral hazards and medicine and, and people have written a lot about this. There's so many good people who've spoke and read about that. And I think the healthcare system so discourages actual health and the practice of medicine, that that makes complete sense to why people would be unsatisfied, unhappy, unfulfilled, and feel in some respects, unethical because they are trapped in a system that treats people so poorly.


So I think when you, you know, Look at the larger healthcare system. I'm like, well, no crap that so many doctors are sad, depressed, suicidal in D P C. It's still a real thing, right? Like, I think we need to talk more about this. Um, I've talked to a lot of my friends privately over the years about this, and so, you know, even though we've kind of escaped this terrible healthcare system and and able to create this kind of idyllic, you know, version of our practices, it's still super, super stressful.


Being a small business owner is stressful. I have a lot of patients are self-employed, and you worry all the time about, you know, whether your business isn't gonna succeed, even if it's 10 years old, even if it's 20 years old. You know, I'm sure you know, even the most successful businesses still worry about that, you know, because no one's guaranteeing you a paycheck.


So I think being a business owner just comes with inherent. Stress. So yeah, I think that's true. And then I also think D P C, you know, if there is a dark side of D P C, it's because we get to know our patients so well and so intimately, which sounds like on the surface, amazing, right? You know, cause oh, you can spend an hour and a half with people.


You spend so much time with them. The downside of that is when you know patients still struggle, right? Like, I, I feel that way all the time. I'm like, I've given you everything I have, and you're still not well, you're still not better. I've used every tool. I've thought outside the box, you know, and maybe they've seen 10 other doctors too.


That's usually the case, and they're still not well. Right. They still suffer a lot and I feel often powerless to fix them. Right. I feel like we feel like we're healers and so they should be. Well, and so I think, I think because we get to spend so much more time with people, we get to know them better, their whole story and, and that becomes even more challenging when people don't do well.


And sometimes, you know, we are powerless. Right. You know, when people die of, you know, stage four cancer. I think we, we recognize that, but you know, when we're dealing with these more kind of chronic illnesses and stuff and people continue to go downhill and suffer, I think that that definitely has a toll on people.


And it does, it does. Me, I think that's part of my increasing emphasis on fitness is that I'd like, well the only way I can reduce misery is that Right? Like, I can't prescribe you enough pills. You know, I can sedate you. At the end, you know, and the end can be weeks, months, or years depending on what you want.


Um, so that, that's probably part of my emphasis of that has been, maybe it's a way out, out of that, or I think it maybe is at an individual level, maybe one of the ways to reduce misery and in life and, and increase happiness. But yeah, I mean, I think, I think we, we definitely need to talk about that. And, and D B C isn't, you know, some complete unicorn where everyone's always happy.


And it's true that a lot of us are still burnt out, burnt out at some level, you know, and, and human just dealing with humans, right? Like it's very taxing and emotional to deal with people who are difficult, stubborn, rude, you know? So, so we deal with that every day and we, we vent like none other here, you know, behind closed doors.


And I think that's healthy and normal, uh, for us to do. But, you know, that's hard to talk about publicly cuz, you know, that comes across as negative or not, you know, caring for people. But it's, it's definitely part of the job. Uh, and I think we need those kind of safe spaces maybe to, to vent to each other.


You know, you call the doctor's lounger. Nurses lounge or whatever, but. You know, some people are just mean that, well, that, that gets old.


It, it totally doesn't, you know, if you're going into D P C I think it's something to be very aware of. Like, I love that there's usually lectures on the dark side of D P C at whatever summit you go to.

Mm-hmm. But I think that, you know, uh, just calling out specific episodes of the my D P C story podcast, Dr. Whitney Webster Pack was a pediatrician at the Four Corners in Colorado. And she, so she, you know, shared how her practice was very limited because she could not take Medicaid patients in the state of Colorado and there was no other pediatrician around.


And her practice closed, but she's still alive, still is very proud of her DPC experience. Mm-hmm. And then look at Dr. Erica Bliss. I mean, Dr. Erica Bliss, one of the original pioneers with Dr. Garrison Bliss, who. Who soared at Q Lions and Q Lions is no longer, and now she has Equinox. Yeah. And so, you know, when it comes to talking about D P C and the experience of D P C I, I do, I've definitely, you know, encouraged people Yeah.


To, to realize that like this is gonna come out in a later episode. But I was having a conversation with Dr. Amber Becken Hower, how, like, I was crying to Hay Miller one day who owns Mountain State's diabetes. I was like, Haley. And she's like, oh yeah, no problem. I was there exactly three months ago. So you keep crying.


You, you, I'm gonna give you empathy as you, as you cry your tears up, cuz you gotta do that. And then we, we, we will go onto the next day and do the next thing that we need to do. And so it is not always sunshine, lollipops and rainbows. And I'm so grateful that you mentioned that. Yeah. Because people need to know that it is, it has its ups and downs, but overall it is flipping amazing.

And like, I'm just like you, I will not go back to Yeah. Um, you know, it's, it's trading, it's trading one type of stress for another. Right. Like, I think, I think in the normal system we have those moral hazards, which are like inherently built in and deep down we kind of feel this, this lack of, of self fulfillment professionally, personally and otherwise.


And like I, and not saying that some people can't just kind of put their head down and, and be okay with that. Like, I have many friends who do and I'm like, awesome for you. And they like, they think they, you know, they're providing great care, seeing 38 people a day, and I'm like, I don't know how you do that.


I feel like an idiot because I care for much less than that and I feel like I sometimes let people down. So, you know, so I think there's the normal system stress and I think that that stress is kind of baked in, whereas D B C stress is a different type of stress. But at the end of the day, you know, you tried your best.


You could give people what they needed and there's other things that may not be great, right? It might be just the person themselves and you have a personality conflict, or it might be business problems themselves. But I think deep down, like you feel like you're, you're doing the right thing and that you have a path to.


Know, self fulfillment. I sound like I'm. You know, Tony Robbins speech here, but I, I don't know, but I think it makes sense to most of it. I agree with that because, you know, the, the people listening are for the most part thinking about their own experiences. Like I, I think about even the, the quote you had from your 2012 Kevin MD article that, you know, if you, you didn't wish to live in Groundhog Day every single day, and there's people who, you know, no matter how you try to escape the, the fee for service world, you know, Deval stressors, fill in the blank here.


When the system is so run by, well, I have to take it to 16 administrative committees before we can actually make change in your clinic or your life, or, we don't, you don't actually matter. You're just here to process the codes For us, it, it can be very disheartening and so people, I'm sure are listening to your words and, and thinking of their own experiences, so, Going from that note to a, uh, an inspirational note to close out our talk.


When you think about people leaving the d p C summit and going forward, because you've, you've spoken at so many D P C summits and you've spoken, you know, to so many people in the national media scene in, in your local communities. When you think about where D P C is going in the future, and as people think about their spot in the D P C ecosystem, what words of encouragement do you have for people who are, you know, really, really wanting to do, be to do D P C, but are just not sure as to when to make that leap?


I think if you're not in D P C, but you're, you know, a family doctor, primary care doctor, looking at doing this, I, I, I, again, I I would say going back to the most encouraging thing is that we have a big community of people who can help you. That doesn't mean it's gonna be easy cuz it's your thing. So people who think this is like a turnkey thing or if they get sold as a turnkey solution from somebody that's probably not part of your tribe or community, or at least not the one you want to be a part of.


So, uh, but there's so many good resources, uh, like all of your podcasts. Uh, I haven't listen to all of 'em, but I've listened to quite a few are great. And you know, the Alliance D B C Alliance, uh, the D P C Summit conference. There's so many things out there now, the Facebook groups that allow you to learn about D P C, but at the end of the day, like it's a personal decision commitment.


You know, you can be passionate about anything, you know, it could be pizza, can be primary care, but you have to make it yourself. You have to make your own, you know, universe, you know where you're at. And that's scary, super, super scary, I think for most people. But you have to decide is that, is that work and is that risk worth the potential of a better life and a better profession?


And I think for most people, that answer is yes, if they're being honest with themselves. But if you're not ready to do that, then don't, you know, I, I think I've seen many people like take a leap of faith, but they weren't willing to put in the time and the effort and the planning to make it work. So I, I, you know, in some respects, you know, I've been saying, oh, take the leap of faith.


And I'm like, well, yeah, you ultimately do, but you'd better have a really good plan and a really good support group around you. And if you do that and you have that in place that you'll probably succeed, nothing's a hundred percent. If being an entrepreneur was a hundred percent successful, then everyone would do it, right?


Like everyone who worked at a pizza shop, which is open their own pizza shop and make more money and be the boss. But it's, it's, you know, you have to, you have to recognize that there is some risk in doing something like this. But if you have a good group of people around you and a good plan, it's a really high chance that it's gonna work.


It's gonna be a lot of work, but it's probably gonna work and you'll probably be fine. But that's ultimately what it comes down to is every doctor who wants to do this has to make. That decision and come up with a good plan. But it's, it's much easier now, I think, than it was in 2011. So I think you had to be crazy in 2011 to try this, but you only have to be like a little bit crazy now.


But I still, you know, in my own universe, people call me crazy, but I'm sure doctors starting this now will still be called crazy, right? So I like to think of myself as special, but it's probably the same thing starting now as it was in 2011. And, and the only people that really matter are the potential, you know, five, 600 people that you need.


So, As patients. No, no one else really matters.


Amen. And that's why I'm so with you when you, you know, opened this whole interview with th this is the way, and this is not the way, like in that we wear Mandalorian helmets and we don't take them off un, you know, unless we're eating. But yeah, I mean, this is the way that we have returned to the old way of doing medicine and are collaborating together to bring this to everyday Americans, this way of accessible, affordable, in incredibly, um, high quality care.


And it, it, for me, it just makes me so proud of each and every one of us who are learning about D P C, doing D P C, doing direct specialty care, because I, I always say like this is allowing us to be the doctors as we went to medical school to be. So with that, thank you so much Dr. Noel for joining us today.


Thank you.


Next week look forward to hearing from Dr. Shannon Schul of Gastro Direct in Raleigh, North Carolina. If you've enjoyed the podcast and you haven't yet done so, subscribe today and share the episode with a physician you may know who needs to hear about D P C. Leave a five star review on Apple Podcast and on Spotify now as well as it helps.

Others to find all these DPC stories. Lastly, be sure to follow us on social media. 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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