Direct Primary Care Doctor
In this special episode, we pay tribute to the late Dr. Buzz Hollander, a pioneer in Direct Primary Care (DPC) from Hawaii, whose unexpected passing in 2023 deeply impacted the world of DPC. Join us as we celebrate his life and legacy as a gifted physician, writer, husband, father, and outdoor enthusiast.
Dr. Hollander was a co-founder of a DPC medical practice in Hawaii, known for his commitment to compassionate care and evidence-based medicine. He combined his medical expertise with a passion for sports, the outdoors, and organizing unforgettable trips. Beyond his medical career, Buzz was a culinary enthusiast, a humorist, and a warm-hearted individual.
His influence extended nationally and internationally through his writing, leaving a lasting legacy in the DPC field. Dr. Hollander's journey began in New Jersey and led to a remarkable medical career.
He is survived by his wife Michelle, daughters Eve and Audrey, and other family members. In lieu of flowers, honoring Buzz's memory involves spending time in nature and cherishing the wonders of life. In this episode, you'll hear Dr. Hollander's own words about his clinic and the inspiration he drew from a friend in medical school who was a DPC physician.
We reflect on Dr. Hollander's dedication to family, self-care, and meaningful patient relationships. Let's be inspired by his DPC legacy and remember the remarkable colleague we've lost.
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Hey there, my DPC story listeners, Mariel here. Today is a special episode and a bittersweet one at that. Almost one year ago today, I had the pleasure of interviewing Dr. Buzz Hollander on my DPC story. He will always be a pioneer in DPC in the state of Hawaii. He passed away unexpectedly this summer, and after finding out about his His passing.
I thought it was appropriate to make sure he had a tribute here with his fellow D P C colleagues. I want to read now what his family has shared about his life. Dr. Robert b Buzz Hollander III died unexpectedly on June 25th, 2023, while flying from his home on the island of Hawaii to Seattle for medical care related to complications from cancer treatment.
He was 53 years old. Buzz was a gifted physician and writer, a beloved father, husband, and brother, whose intense intellect was tempered by the joy he found in wild places and the people he loved. His family was the center of his world. He proposed on the side of a volcano to Michelle Subar, the woman who became his wife and poured his heart and spirit of adventure into time with their two daughters, boogie boarding on a flooding creek.
playing a wood troll for a birthday party, or happily clucking over their beloved Rhode Island red chickens. Buzz held out fax for careful observation and plunged wholeheartedly into his many passions. As an athlete, sports fan of the Pittsburgh Steelers and New York Yankees especially, and consummate outdoor explorer, Buzz grew up sleeping under the stars whenever possible.
He cultivated a love of wild places throughout his life, from childhood trips in the white, great Smoky and Blue Ridge Mountains, to adult forays to Nepal and Guatemala, as well as the Maroon Bells, North Cascades, and High Sierra. Buzz was the self appointed trip organizer, poring over maps and mining his photographic memory to create epic outings for others.
He celebrated his 50th birthday with a round trip 40 mile trek from the family home to the sacred summit of 13, 803 foot Mauna Kea. The king of the airport pick up prank and a masterful poker player, Buzz was also a great cook, whipping up dishes with something extra, artfully arranged or with fresh flowers rimming the plate's edge.
His legions of friends spanned decades and thousands of miles. A conversation with Buzz left you heard, challenged, loved, informed, and lifted. He shared hilarious, caring messages with friends and family. But it's the generosity, warmth, and light of Buzz's physical presence that's most sorely missed by those who love him.
As a physician, he was driven by compassion and a drive to learn. Together with his wife, Buzz founded a direct primary care medical practice on Hawaii Island with a loyal community following. His sharp mind and thirst for learning spurred him to begin writing articles on medical issues, applying rigorous analysis to help his readers make informed decisions about their own health care.
His centrist, data focused perspective and clear, entertaining writing style had attracted a growing number of followers around the country and world. Buzz grew up in a rambling yellow house on 10 acres of forest in Hopewell, New Jersey, and attended schools in the Hopewell Valley Regional School District.
He graduated from Princeton University in 1991, completed his pre med education at Appalachian State University in Boone, North Carolina, and earned his medical degree from the UNC School of Medicine in 2002, before finishing his residency at the Santa Rosa, California Family Medicine Residency Program in 2005.
Buzz was preceded in death by his parents. the scholar Robert B. Hollander Jr., and the poet Gene Hollander. He is survived by his wife Michelle and daughters Eve and Audrey, sister Zaz, brother in law Leo, and nieces Josephine and Anika. In lieu of flowers, feel free to wander in the woods with loved ones, devise various elaborate and heartfelt pranks, and revel in the wonder of it all.
In his episode that you will hear today, you'll hear about the why behind opening his clinic, Iris integrative health with his wife and also how he received inspiration and guidance in opening his practice from one of his best friends in medical school, who was already practicing as a DPC physician. I mentioned this because as you listen, think about who you've inspired when it comes to learning about DPC patients and fellow physicians, especially as DPC means so much to so many of us.
Time with family, time for self care, time for building meaningful, fulfilling relationships with our patients. In whatever time we are lucky to have, let's make the best of it, just like Buzz did. We have lost a great colleague. So as a tribute to Dr. Buzz Hollander, here is his story, in his words.
Direct primary care is an innovative alternative path to insurance driven health care. Typically, a patient pays their doctor a low monthly membership and in return builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the MyDPCStory podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen To practice medicine in their individual communities through the direct primary care model.
I'm your host, Marielle conception family physician, 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.
I came to Hawaii from my Family Medicine residency in Northern California in Santa Rosa. And I just met the woman is now my wife. And I started work at a community health center in a very rural town. And I did that for seven years. It was all held together by an ER gig and a rural ER, which made that all financially and practically possible as we started our family with two daughters now.
And we hit a point where that ER gig was going away. As our clinic had lost the contract. So my wife, who's a naturopathic physician and I decided to start our own practice. She was going to continue doing cash pay fee for service with her patients and we would share an office and I would accept all sorts of insurance.
We did that together for four years. And I hit a point where it seemed like at the end of every day, I'd be getting in my car, and I'd have this list of things that I hadn't gotten done that day. Patients I hadn't called, specialists I hadn't checked in with, referrals I hadn't made. And I realized that I was really wearing down, and not loving the work I was doing anymore, and feeling like I wasn't able to do the job that I wanted to do, which, for me, centers around having relationships with my patients.
patients that are meaningful and being available to them when I needed to do my best possible work as a physician. And on top of that, financially, we were barely getting by trying to hold this together in a model where I wouldn't be seeing 25 or 50 patients a day, but just 15 or 20. So it struck me, I needed to change.
And my wife and I had a lot of discussions about it. We did a lot of planning and finally in the summer of 2016, we opened our own practice. It was direct primary care. We built it up since then and it's been really meaningful and all in all. Great ride for us. My name is Dr. Buzz Hollander, MD. Our practice is Iris Integrative Health, and this is my DPC story.
Dr. Buzz Hollander has been a Big Island physician in both clinic and ER settings since 2005. While traditionally trained in Western medicine, he prefers an emphasis on healthful lifestyles and evidence based prevention of illness. Approaching the source of chronic medical problems rather than simply treating the symptoms and recommending the least invasive treatment options in times of acute need.
Dr. Hollander graduated from Princeton University in 1991 and attended the UNC Chapel Hill School of Medicine from 1998 to 2002 before completing his residency at the Santa Rosa, California Family Medicine Residency Program in 2005. He is fortunate enough to be married to Dr. Suber and share the parenting of their two daughters.
On a day off, he likes to be near the water, hiking through Hawaii's native forests or tending to the land. Together with his wife, he has been practicing at Iris Integrative Health since 2016.
Welcome to the podcast, Dr. Hollander. Thanks, Mariel. I appreciate being on it. I think this is so cool because as DPC has expanded over the years, this podcast is expanding its episodes to reach Hawaii now. So for all of those of you who have wondered how is DPC practiced in Hawaii, Dr. Hollander is going to share that today.
It's practiced with Aloha, of course. I love it. I just like knowing that we were going to be speaking today. It's almost like you could feel the breeze. It's just so much more relaxing just knowing that you're in Hawaii. It's coming through the zoom lens. So that's awesome. So I loved your opening statement in terms of it really gave a roadmap as to what your journey was like on a global view.
I want to go back to 2005 when you graduated residency in Santa Rosa. And at the time, you know, when you were looking at. Prospects as a family medicine doctor after residency. What was on your horizon? I was very happy with the idea of having a job, any job. And I think a lot of people fresh out of residency have that feeling of, Oh my God, somebody actually wants to hire me.
I know nothing about medicine, but I felt extremely fortunate. The place where I was moving to was On the big island of Hawaii, and your listeners who are not familiar with Hawaii geography, the big island is not Oahu. There is nothing on the big island. There are two small, medium town cities, Hilo and Kona, whole population is under 200, 000, and it is a huge island.
It is the size of the state of Connecticut, so it's rural, it's medically underserved, and we happen to be in a particularly rural part of the island between a couple of small towns, Honoka and Waimea. And it just so happened that there was this community health center literally down the road, 15 minutes from the house that my wife had just bought.
And I was thrilled to be able to get a full time job there. And then that morphed into a little less than full time. And they had a little rural ER, which had just opened up. If you've ever worked in rural ER, it's, it can be very easy in terms of You get paid for 24 hour shifts and you get some sleep most of the time.
And then every now and then you get terrified from something that maybe you weren't fully trained to handle, but it all worked for a while. And it was a great job out of residency for me because I had five colleagues, other MDs who were in the building that I could go to for help and counsel and. Best of all, I was in this rural, really culturally rich place working in a setting where I was getting to meet everybody.
I mean, from famous celebrities to a lot of multi generational Hawaiians, people who had recently been laid off when the plantations had closed on that side of the island. And it was a great entry into Hawaiian culture and the community in a way that would have been very hard if I'd gone right into private practice.
Awesome. And I love that because, you know, especially as you talked about in your opening statement, relationship based care really matters. And when you are part of that community that you're living in and you're really attuned to who is in your community and their needs, it really makes a difference in their care, especially under the DPC model.
Absolutely. So when you talk about Hawaii and how your experience post residency started, I want to just ask, did you guys always intend to buy a house in Hawaii and open practice in Hawaii, or was that something that just happened? I will say my wife knew for a long time that she belonged in Hawaii and she was, her timing was fortunate for her.
She finished naturopathic medical college in Portland, right when they were kicking off a naturopathic residency program here on the Big Island. Earl Bakken, who was a pioneer behind the pacemaker, was starting up this new hospital that they wanted to be the Mayo of the Pacific in our little town of Waimea.
It didn't work out quite that well, but it is still standing. And part of that was trying to have a real focus on integrative care, which was something that was important for him. So he was starting this naturopathic medical residency. And my wife was the first enrollee in the program. And it was. So great for her because she comes right in and is working with the best known cardiologist on the island, the best known intensivist and internal medicine doctor on the island, the best known OBGYN on the island.
So she was getting her medical training from these very well respected people that gave her a relationship with these other physicians that I think helped overcome some of that you're a what kind of doctor when she would call them. And she was also working with a very well established naturopath in Kona.
So she was set here. And knew it as soon as she got here that the Big Island was the place for her and has never looked back. She's never doubted it. For me, I was very happy in Northern California and planned to stay there. But before I finished residency, I put together a month rotation out here and I was introduced to her and that just was Changed everything.
So I didn't plan to live here. It just worked out that way. And when we were both practicing physicians here, never for those first seven years, did it even cross my mind that we should open a private practice together? To me, that sounded like a bureaucratic nightmare. And I just, I had no interest in all that extra work.
That's awesome. And I'm sure that your patients and your daughters are so happy that you guys ended up finding each other and creating this amazing clinic. Now, when you talk about how somebody Envisions a clinic, the bureaucratic nightmare, the typical fee for service codes or what are driving our care.
And you guys started having the discussions about how could we practice while still being able to do the medicine that we want to do and what and where in that journey, where in that discussion did you guys learn about DPC? Later on in the game, I think I was clearly naive in starting my side of the practice when my wife and I joined forces.
In terms, like most people, was overly optimistic when I did my numerical calculations. I convinced myself that I could make a normal doctor's salary seeing 16 patients a day. Doesn't really work that way once you factor in overhead and reimbursement that doesn't get paid. And, you know, there's vacation you're going to take, there's days you're going to miss, kids are going to get born.
It's hard to hit what are understandably optimistic targets when you're sitting there with a piece of paper and pushing numbers around trying to convince yourself, yes, you can do this. And. It was hard. I think the hardest thing about having that sort of fee for service insurance based practice was especially as someone who likes to be outside, likes to travel.
My wife and I really, we started backpacking as soon as we met and then we started having a family. So that desire to have some flexibility. It is really a hard push up against the realities of fee for service insurance based practice where if you are not in your office you are making zero money, unless you figured some other stuff out which I never figured out and believe me it was not for lack of trying, you know, can't I.
Can I answer phones for the local insurance company? Can I find some, somebody that wants me to consult? Like I could never come up with a side gig other than the ER work. And when that dried up, it really challenged me to find a way where if I would look at it. Two week vacation. So we could go back and see our parents who are all on the East coast at the time.
It's one thing to figure out the cost of the plane fares and the lodging and the car, but then you'd have to factor in, I am not going to make any money. I'm going to have to keep paying my staff because we can't just close our practice. We are a primary care practice and it is just painful to take a day off for something important.
It was hard not to say like, wow, that's whatever a thousand, 1, 500 gross that I'm never going to make that's going to hurt me at the end of the year. It's, it's incredible how fee for service is not, it's not a simple equation. You see a patient, you get paid. It really isn't, especially if you are in private practice and doing fee for service.
And then separately, there are different challenges when you are an employed physician in fee for service these days. So thank you so much for sharing that experience. So you mentioned how you learned about DPC later in the game. And so as you were experiencing these frustrations with Fee for service and reimbursement and the time with your patients being a challenge in terms of you couldn't just call somebody up on the phone or did, you know, do care the way you wanted to.
How did you come to learn about DPC? I was a little embarrassingly slow to the game, giving that one of my best friends from medical school at UNC Chapel Hill, a fellow by the name of Brian Lewis, he had DPC practice in Asheville as an early adapter. I mean, I would say I probably shouldn't guess, but I mean, it was well over 10 years ago, I would say, and his was a low cost model.
I think when he started, it was only 40 or 50 bucks per member and he was really trying to do community based medicine. And he, like me, had, came into it with a, whatever you want to call it, integrative bent, or an interest in non conventional medicines. I was aware that he was doing this. And for some reason, I think I dismissed it as, that is too hard.
I could never pull that off. And I think that's something that's the self talk that a lot of physicians who are interested will, will have that, Oh, there is some special magical quality. That somebody needs to be able to pull off a DPC practice. And I, I just remember being told, I think it was in residency still.
I maybe mentioned that I, one of my college friends, all my college buddies are in finance pretty much. And so one of them was also, he would send me these emails periodically at the start of the DPC and concierge medicine movement. Hey, if you check this out, you should absolutely do this. You could pull this off.
And I would just, I probably brought that up to one of my mentors said. He told me about some study he had seen where people's willingness to spend something like an to drive an extra three miles to see a doctor they considered better was close to nothing. I mean, he really impressed on me. Your patients will not do anything beyond the minimum to see you, even if they love you.
And I think that had really gotten deep in my psyche that. patients are incredibly unmotivated to get to pay extra to go farther to get what even if they think it's better care and that it really stuck with me and it was the thought of DPC as I started to contemplate it as the only solution I could come up with in my mind.
It was still terrifying. I mean, really. I'm a good sleeper, but something akin to sleepless nights as we got closer to that decision. I was so nervous about it being a financial catastrophe. Absolutely, and that it is a huge fear that a lot of people have, especially those who are in residency to choose DPC right out of residency.
And while there are many examples as to how many people have. Answered. How am I going to overcome this fear or get through this fear on the podcast? Even everybody does it differently. So when you guys were at that point, when you were having those sleepless nights, what were some of the discussions and the planning that took place to open your DPC?
One thing. Was I probably had a three hour long conversation with my friend, Brian, to which I probably haven't thanked him enough for, but really going through how he did it, what were the obstacles, what was the startup process like, and what was also enormously helpful, which is why I was so happy to join you on your podcast was back in the day in 2015 or early 2016, when we were pulling this together, because it was probably a podcast.
Full year long planning process. Once we decided we're going to do this, I think the only real resource I could find in terms of podcasts was concierge medical today or concierge medical radio. They had, I saw, I think it was 29 episodes. And I may have listened to most of them twice or three times because they spoke with some real leaders of the field and also some people who.
had practices you'd never heard of. And I soaked up those interviews. It was so helpful for me to hear. There were so many different ways to skin that particular cat of trying to open a DPC practice. And it was a lot of consideration and then starting to try it on. What is the sort of practice? Obviously my wife and I wanted to work together.
We already owned our office building or our suite anyway, together. And We already had a little bit of a direction in terms of, well, this had to be some sort of integrated practice because we had to integrate what I was doing with my medical training and her naturopathic training into a practice together.
So there's always going to be a little bit of a niche there, but our biggest task was how do we attract the people who are already our patients to stay with our practice and then go on from there and attracting more people in the community to it. I love that. And so with that said, I just want to take a global step back and think and ask you about what was the DPC scene like in general, because you talked about the very sad lack of resources at the time, but what about a DPC presence in Hawaii in terms of the other islands in terms of, you know, you explained your rural area, but were there other DPC clinics open at the time that you guys decided to go DPC?
I believe that there were zero of what you might call true DPC, and I'm sure you've gotten into this in past episodes that how do you really decide what's concierge, what's DPC, but if we're going to say a physician who is taking payment directly from members and not accepting insurance, then there was, I think, a certain concierge company who will go unnamed had five or six members.
Physicians on Oahu. That's very much a concierge model. As I was going into it, several other physicians, one of them on our island in Hilo, he transitioned a practice from his big community practice into more of a DPC. model. Another woman who's I'd known through her hospitalist work, tried to start a DPC practice in a nearby town, but could never get it off the ground.
I had connections with a woman physician in Oahu that tried to get one going. I don't know that she's ever succeeded. And that was really the context in Hawaii as we were getting started, which either meant it was a fabulous opportunity or we were crazy. I'm so glad it's, uh, it's not the latter. So again, your community, I'm sure is also very grateful that it wasn't the latter.
So now I want to go back to your guys's experience, because when you talked about, you wanted To work together. You already have the suite. You own the suite and you wanted to attract patients. What was your ideal clinic under the DPC model? And what, who was your ideal patient? My wife wanted to continue on with her naturopathic practice.
And ideally keep as many of her patients as possible, who after all were used to a cash pay model, but of course, it's a big and somewhat difficult mental transition for medical consumers who are used to paying cash for their medical advice. But are also used to choosing when they get to pay cash and how often they're going to pay cash.
So that I haven't looked at this. My guess is we probably retained a similar proportion of our patients, but it was an interesting sell to her pace to try to explain how this was going to be different going forward. For me, I had not done, I love doing OB and prenatal care and early pediatric care in residency.
I thought I would want to do that after I graduated, but there was really not a lot of support for that here on the Big Island. It wasn't being done by the other physicians that I was working with in my first job. And I let it go. And as I started having kids of my own, that felt like an easier decision in terms of the hours demanded by doing OB care.
But we do have a lot of kids in our practice. So we do a fair bit of prenatal care, which my wife does most of and increasing amount of pediatric care. Uh, it's just the ebb and flow of our practice. So we definitely want it to be full spectrum cradle to the grave and that sort of perspective. The way that we approached our work together was that I would be in the clinic three or four days a week.
My wife would be in the clinic a day or two a week, and we would try to spend at least half a day together where we could see patients together, which is incredibly inefficient in terms of the use of our time. And to be honest, we've done less of that as the years have gone on. Because we often feel like, well, somebody can really see one of us and we can write a note.
We can shoot a message to the other and integrate our care that way. But I always loved it. It was really fun. It was very helpful for me in honing the way I wanted to practice medicine, to watch the way my wife would interview a patient from a naturopathic perspective compared to how I would. I mean, she would ask these, what to me at the time seemed like excruciating detail about what do you eat?
What do you drink? What do you do in your free time? How do you like your job? I couldn't relate to any of it. My dietary questionnaire as a conventional medical doctor was, you know, how's the quality of your diet? It's good. Okay. And to see her practice like that, I can't do it any other way. It's one reason why my new patient visit time has kept creeping up from 45 minutes to an hour and a half, two hours for a new patient visit, because I want to get all those details.
And I've learned the importance of them. And that's, I think really where medicine can make a difference is when you start addressing those fine details on how people live. In terms of like the patients who did come over, did you find that you knew your patients even better than you did when you took care of them before in the fee for service model, because you had the time to ask the questions that you wanted to.
Absolutely. And some of my patients that by that point arrived on the island 2005. So by the time we're transitioning, I've been on, I've known some of these patients for over a decade and some of these patients had remarkable stories and I had no idea. I had never asked, never had the time to ask and to have that time to hear their stories is one of the great things about this practice model.
So going back again to those conversations that you had prior to opening and you were thinking about, okay, who would join us and the verbiage, the copy that you would have on your website, the verbiage that you would use to describe direct primary care as a model different than just, you know, you're paying like a chiropractor visit, or you're paying with your insurance card, who was your ideal patient and how did you reach those patients who decided to join the practice?
That was a huge advantage of Moving from an established insurance accepting practice with a fairly large size, we probably had about 1500 patients who are really our patients at the time we transition, is that you get to do an audition for almost all of them. And that's one reason why people who want to start one of these practices right out of residency need to listen, the folks at Atlas.
Medical in, I think they're in Kansas City area. Like they're fantastic and they help me a lot. They're so giving of their time and they're still appreciative of, of their help, but they're the inspiring story for people that just graduate from residency and go out and beat the streets and attract patients.
That would've absolutely terrified me. I just didn't have a confidence for that. So for me, I really wanted to work the angle. good relationships with a lot of patients, like most doctors, the people that stick with us over a decade are the people that like us. Everybody else finds someone else. So, I mean, the ideal patient was anybody that wanted to work with us and pay our fees.
I mean, that we just wanted to attract enough people to not go broke in the first two months. But what we really want are the people that were ready to really People who wanted to take advantage of the time that we would be able to give them a greater depth of care than just all right, let's do our annual labs.
If something's out of whack, we got to treat it and then I'll see you back in four months and see if it worked. One thing that was very interesting for us is we almost totally inability to assess the people who are going to stay with us on the advice of a business savvy friend and patient. who suggested we do these focus groups before we roll out our announcement.
So we picked out, I think, 20 people, 15 or 20 people, and we had two different dinner meetings with them where we pitched our idea to chance to feel people out. And these are the people that we felt like they love us. They're the ones that we asked to give us positive reviews for our website. And we did these two nights with these patients who are handpicked to be our eventual joins.
And I think the join rate was Might have even been lower with those 20 people than with the 1500 patients in a whole. We completely misestimated their interest. It was a humbling experience in that regard to see these people that we thought we had real physician patient relationships with and the means to afford our practice say no to it.
And on the other hand, there were people retired. School teachers and hotel people work in the hotels down at the coast, barely making it who shocked me and basically saying, I couldn't imagine seeing another doctor or what's more important to me than my health. Like, I can save in a few other departments here.
Now, it can be a little painful and we can get into that whole, the shadow side of DPC is that once you start charging money in a place where like Hawaii, where. almost everybody has medical insurance, then you're going to lose some patients and some of those people you're losing because they simply can't afford it.
But there are a lot of people, incredibly wealthy patients, who I thought really cared about the service we gave them, who walked away saying things like, well, I've got Medicare for that. And it was really shocking. And overall, we were incredibly Blessed that we had good relationships with enough patients who valued our work.
And we probably retained almost 10 percent of our patient base, which is great. It was above our minimum threshold to not have interruption in our income stream. So that whole thing was a dream for us, how quickly we filled up our practice and were financially viable, but it was not the people we expected to stay with us.
That's such great insight. And that's incredible. 10%. I mean, that, that is huge for a practice transitioning over to DPC. That's such a testament to the value proposition that you guys were bringing and how your patients who joined really valued, like you said, their health and access to care to a doctor who knows them.
So that's wonderful. Now, when you guys were transitioning, can you touch on any special things that people should think about or things that you had to go through that were unique to Hawaii? To open up a medical clinic that was under the DPC model. Well, I could answer that in a couple different ways.
I'll start with the big picture being, what was really helpful to me about those focus groups was that I had to come up with what the pitch really was. And it's amazing how we can not really know that about ourselves because I didn't. And that became second nature as I over and over again, everybody that I saw for about a three or four month period, I had to squeeze in a little two or three minute pitch about, Hey, I got to tell you what we're doing.
And this is why we're excited about it. And I really hope that you can join. And they're often a lot of questions, but knowing what it is that you offer. And I think some people have this sense of, Oh, if I'm not Harvard trained, and if I haven't been published in AFP journal, then how can I possibly claim that I'm worth something more than the other neighborhood doctors that are available with a 10 copay.
And I think it is really important to really feel into what is it that I offer so that. I am worth it. I don't think the model sells itself. I mean, to a certain degree, there are a small handful of patients who were thrilled like, Oh, this is great. We'll have better access to you. Almost everybody understood why we wanted and needed to leave the insurance model.
We got almost no negative pushback. Everyone was like, Oh, I wish I could stay with you. I really liked you as a doctor, but I totally get why you're doing this. It's hell what they're putting you through. I get it. But for those who are, who had the means and the interest in staying with us, it was so important and is so important for a potential DPC physician to communicate what it is that makes you special or special in a different way than another doctor who's still just going to charge them a 10 copay.
And it can be so many different things. It does not have to be that you are the world's best doctor that you trained at the best place in the country. And I think that's the important thing for me. What I felt like I could offer to patients is genuine caring. And I think a lot of people can offer that, but everyone's got a different personality and I can't help it.
I care about my patients. I care about their stories. I like hearing their stories and people knew that. And so. When I was saying, I can't do this 15 or 25 minute model anymore because I need to hear what's going on with your son's soccer league. And I need to find out what happened when your father died on the mainland.
And I just can't not do that and feel like I know you and can really care for you as a person and a patient. So I think people got it. That was what they were paying for. was to have me listening to them and able to do my best job at coming up with a plan for them. I think they also understood that I like to practice medicine in a little more nuanced way than just, I'm going to follow every single recommendation that every major medical organization has offered.
I can be a little cynical about big pharma. I can be cynical about big supplement too. And that's something that, again, it folds well into the notion of. I need this extra time with you because I want to think a little harder about things than I can in the current model in which I'm practicing. And my patients responded to that at a high enough clip that we were able to keep this thing going right out of the gate.
And I'm still grateful for that. Now, in terms of the Practicalities on the advice of the Atlas folks. We took on their lawyer that they use to get the sort of nuts and bolts about what you can and cannot do. How to make that transition from accepting Medicare to being non par is also scary, but it is just certain things you need to do.
How to opt out from, because at that point we were accepting. Probably five or six insurances at least. I mean, Hawaii is a smaller market, but it's still, it's a lot of bureaucracy and you got to do it right. And you got to do it legally because there's just that sense of, I'm sure most physicians when they transition from accepting insurance to moving into a non insurance model do fine.
And there's not any saber rattling in their direction, but I think there's an awareness that somebody might not like what you're doing and might try to make your life difficult. So I leaned on a lot of different people. Spent a little more money than I wanted to spend getting legal advice, but just trying to do everything right.
So that by the day our door opened, we were free and clear of any possible medical legal problems. Love it. And you mentioned that you guys had planned the transition over about a year's time in terms of going through the legal processes that you needed to doing all of the admin stuff to prepare to open.
What timeline would you recommend to somebody if they were thinking about opening DPC specifically in Hawaii? I, that worked for us and it was, I would say the level of labor was kind of similar to anyone that's gotten married and decided not to elope. I mean, for us, it was probably about six months, but it feels like you've got a second job that whole time.
You're working so hard. It seems so simple, and yet every little subtopic could have hours of work and emails and decisions to make. So, I would say it had that kind of feeling in terms of so many details to attend to that I think it really was a solid year. Our target was to announce, we opened on June 1st, and We announced on March 1st to our patients and started sending, you got to send letters out there.
Everybody has to be formally notified when you do something like this. So you're not a patient abandonment issue. So it was 9 months to have everything in a row. And that's because you're talking website and the legal stuff and changing contracts and figuring out your financials and how much do you want to charge and all these conversations to have so that was a very full nine months.
And then from the day that that we went live with the website and started telling people okay. You can sign up for this. Those three months were just utter insanity in terms of the drain of constant conversations and oh my god the website is down and all these things and you can't predict them all.
But I love that you guys have just celebrated your sixth year anniversary and It's worked out so just like how you might have that negative self talk when patients you expect to join don't join. If your business is not doing the thing that it's supposed to that day or your website's broken, there's still hope at the end of the tunnel.
And I will say that. Leaning on other people who have been there, done that is very helpful in this community. And there's lots of ways to do that. All the guests on this podcast have extended their contact information. That's a place, the Facebook groups are places going to conferences. There's always ways to reach out to physicians in this community.
And I feel that in this particular community in direct primary care, that it's really awesome to have somebody just like yourself, you're excited to be on this podcast because. You benefited from hearing another person's story and having the help from the Atlas team. There's always physicians around who can help no matter what state you're in.
So I think that's so awesome. Now, and in terms of your clinic, are you guys an S Corp? Are you an LLC? What is your entity under specifically legally? I forgot about how many hours we had to sink into that. We are an LLC that files taxes as an S Corp. Gotcha. Yeah. That's, it's very interesting to hear everybody's story behind that.
So that's awesome. Yeah. And that's the part that I liked the least about all of this. It just, it's a time sink up front that never. Completely goes away. But I want to be very clear that even though I might whine a little bit about having to deal with complicated taxes every year and such, within three months of having changed our practice, there is no amount of money that could have dragged me back to any of my old jobs or any of my colleagues jobs.
I mean, there is a survivor's guilt that goes on for when you go into DPC. I would see my colleagues around town and they would Give me this look or say, yeah, we're all pretty jealous of you. Buzz. Like it's a tough system and it was really grinding us all down. And nobody, or it seemed like almost no one was happy within that system.
So there's that making peace with the fact that I now had a job that I loved. That was really hard for me on many levels before making the change and that other people were still stuck with the job they didn't love that they felt like they were still stuck with. And that just comes. With the territory, obviously, there, there is a growing interest in this sort of practice for those very obvious reasons.
I don't think anybody is claiming that the changes that are being made in terms of pay for performance is making their job more lovely and gratifying. And I just, I hope that I helped her, but a physician on Kauai. Who has just opened a DPC practice and she's pretty much opened with a wait list. I think she's been incredibly successful as I thought she would be, but she picked my brain for many hours.
I was so happy to do that for her because of the brains that I'd picked along the way. And she's done a great job. And I thought that she would, she was in a good situation there, but there are places. Kauai is a great example and Maui probably would be too, where there is I think an unmet need for people for potential patients who want more than being part of a huge medical organization and having to really compete for the limited resource of a doctor's time.
And happy to help people that want to try to figure out those details here in the state. That's awesome. And one thing that I want to ask about is when you had mentioned how, even though geographically you're on the quote unquote big island, the population is small compared to some of the populations on the other islands.
If you are a physician practicing for a company and then wish to do DPC, do you have to worry about non competes in the state of Hawaii? Yes, that was a huge question for me when I started because originally the health center where I was working had agreed it would be okay for me to start my practice about 18 miles up the road in the office that my wife was already in.
And then someone on the board got cold feet about it and they rescinded their offer for that and having to go farther out. So it was a 20 mile non compete is what I had agreed to. And I'm a pretty legalistic thinker. And so I just thought, okay, well, they've got me, but I just happened to ask a lawyer patient of mine who's a fantastic lawyer.
And he wanted to support me. And it was. We'll just say it did not seem hard for him to get them to agree to let me practice within that 20 mile radius. But in theory, that would have been a year of having to practice very expensive office rental long commute and all of that. So people have to know what they sign.
They need to. I didn't even think about it when I signed that contract and. From what I can tell, it seems like most practices don't want to enforce a non compete clause. Nobody wants to go to court saying, we don't want to let this doctor practice in your underserved community. So I think most people can wriggle out of them with some good help.
But that was a big stressor for us when we were starting this. Absolutely. And again, I'm glad that you showed your experience because it's something for people to think about, especially if they're going to sign on to a fee for service clinic, or they're already in one and they have to look at their contracts to see if it's there, if it's enforceable, et cetera, et cetera.
And having the chance to talk with a legal expert definitely can help. Now, when we talk about your guys clinic. Like you said, you guys are pioneers in the state of Hawaii. And so how did you even come to the rates that you came to when you were opening your practice? That was another time sink to be certain, because that seems like such a big decision.
And I think it really is. I really wanted to, for me, I was stuck on this notion of It should only cost what people pay for their cell phone bill. So I really wanted to start around 80 or 85 for an adult member. And my wife felt like that was too low. And almost everybody else we talked to agreed that was too low.
In terms of the service we were providing, what was the going rate at the time? In the end, I'm grateful that I got talked out of that. I'm very stubborn. It took some convincing, but We ended up starting at 125 for an adult member, 110 for a spouse, and then children were inexpensive. I think one to two kids was maybe another 30 or 40 on top of that.
Looking back on it with 20 20 hindsight, I think we lost very few patients. Because of that 45 difference, I think most people were really pretty set like no way I'm going to pay extra. I'm already paying 1, 000 a month for my Blue Cross Blue Shield health insurance. There's no way I'm paying another 100, 200 on top of that.
And yet it made a huge difference towards our financial viability. That we essentially opened with 150 patients or so meant that We maintained our income, and if we open with that number of patients at 80 or 85, it would have been a substantial hit. It would have been tight for us for a while, and it would have been more pressure to build the practice.
And I've also come to realize about me, that the lower your price, the more patients you need to have for the same income. It's a very simple math, and I encourage people. To really go from there when they try to come up with their price, it's not what the person in the next town overcharges. And oh, my God, that person's only a nurse practitioner.
And I want a teaching award on faculty. So I should charge 30 percent more. I really think it should come down to how many patients do you want to see? Do you want to care for? And a lot of DPC practices will talk about caring for 6 or 800 patients is a good cap. That would overwhelm me because it's If you can again, do the math, how many hours do you want to work per year and divide that into six or 800 people?
It's not going to be a lot per patient, maybe an hour and a half, two hours. And I knew I wanted to do that with every new patient. So we felt like the right number for us is probably around 300, 350 patients. And then you got to figure out how much money do you need to make here in Hawaii? Need to make more than.
Even you in California, probably, and that's a lot more. I saw you train at Creighton. Like, that's a lot more than you need to make to have a nice house and a nice car in Nebraska. So you need to factor that in. How much money do you need to make? What's your rough on the overhead? Tough to figure, but we knew we'd be about 150, 000 a year in overhead.
So we could calculate that out. And if we wanted to keep our practice in the low 300s, had to have that price point more in that 125 range than the 80. I'm grateful we did it. It would have been very hard to get up to five or six hundred patients, and I'd be a little burnt out by now, honestly, the way I like to practice.
Everyone's different. If you are a physician who likes volume medicine, likes doing DERM procedures, likes getting people in, tuning them up, and getting them people out, and are frankly not that talkative or... Just you gotta be honest with yourself. If you are a brilliant tactical physician and you know, you kind of hate it when people start talking about what their kids are doing in college, that's the model for you.
Like lower price, higher volume, go for it, book it out. But for me, that wasn't the way. And so that really helped us. And it was the right number for us. Like in retrospect, I can say it was the right number. We increased it to new patients to 150, I want to say, or 145 and 125 for spouses. When we've started a wait list.
So in a couple of years in, we started a wait list. We felt like, okay, maybe we were a little low in terms of supply and demand. There was a lot of wealthy people starting to move to the island. So we bumped our price. And now we're about to with inflation and all that, we're going to start another for new patients.
We're going to raise it up to 200, which feels really high to me. But the reality is we've got enough patients. They're loyal. We love them. They seem to like us. And there's a lot of people moving here. Now this money is a drop in the bucket to them. And it's. Different depending on if you're trying to have a blue collar practice, you're going to look at a different price, a bigger practice.
It's if you've seen one DPC, you've seen one DPC and listening to your why and what are the reasons you're choosing to do DPC if you choose to do DPC is so important because that really your practice is your practice and it's not a cookie cutter model. So when we talk about the patients who have joined your practice, the fact that you guys reached already a waiting list in your second year.
How did the growth happen in terms of that 10 percent did that 10 percent on board within the first month, within the first week? And how did it grow in terms of numbers to get to that point in that second year when you were accepting a wait list? I had a file somewhere where I actually tracked that by the week originally, because I was so nervous and so excited about it and it's gone.
Apple ate it. But my recollection is that when I was looking at this for another physician who asked recently, I think we had about a hundred patients before we even opened our doors. So a lot of that 10% were just right at the beginning, signed right up, and then we got the other few percent to get up to 10%.
We had 150 patients I think before we were done with our first month. And then after that, it was a sort of slow organic growth. A few people who had gone to other doctors and were completely unhappy with them and came back to our practice. Mostly, though, it was new patients, word of mouth. To the point where, because we were told over and over again, don't bother advertising.
People do not choose their doctors, especially doctors are going to pay money for it by a clip on the radio or in the newspaper or whatever. So we didn't. I mean, we did virtually no advertising. I'm not much of a self promoter and neither is my wife, so. We weren't out there doing what's usually recommended about you got to beat the streets.
You got to go to every club and meeting and get your names out there. I recommend that for most people. It just wasn't our style. And so it was almost exclusively word of mouth. When someone joins a practice, we have a new patient. We say, how'd you hear about us? Oh, We're just looking online. It's sort of a seriously, like you don't even know who we are.
And you're here. How interesting because almost everybody it's their neighbor. It's neighbors. People talk over drinks at cocktail parties out socially, everybody that's new to a place or is unhappy with their doctor. They ask the people they like and trust, who's your doctor? And if they're pleased with what we give them, it's, Oh, you should go check out Dr. Hollander and Dr. Suber. They do a great job. It's kind of a weird practice model. Like go look at them on the internet. So that's how we get, that's how the growth was. And it was just slow and steady from that point on. And then in terms of who is working at Iris Integrative Health, is it yourself, your wife and other staff, or is it just the two of you?
We definitely have always had staff. I love the idea of a micro practice. When I was coming up through residency, it sounded so tight and efficient and cool. And now I just can't imagine doing it. I know that people do, and they must be such efficient human beings. Because to me, it's daunting the idea of, well, who's going to send the referral, who's going to bug the insurance company to get that MRI paid for, who's going to call the pharmacy for the seventh time to get a prescription, right?
So we always had, we started with an RN who was fantastic. He's now a nurse practitioner, but he was our do everything at first. So he would do vitals, he'd do EKGs, he'd give vaccines, whatever, as well as. Mind the phones, make the appointments, deal with the problems. He was unbelievably efficient, former Israeli military.
So he was a great first choice for us. Right now, we don't have a nurse on staff. We have two staffers who both work a little over half time and they just keep things moving. They make sure someone's always there to answer the phone and handle all the stuff that my wife and I don't want to, or don't have time to handle and just make it a smooth process that works for us to have.
Basically one person in the office all the time. I love that. And it really, again, goes back to your why, like you mentioned how you were sitting there in fee for service and always feeling frustrated with the list of things that you hadn't gotten to the referrals that you hadn't sent to the specialist that you hadn't contacted, et cetera.
And so absolutely. I think that's wonderful that you have found that this works best for you guys and how you want to practice. So that's awesome. Yeah, and I also totally get that if we were a higher volume practice, we'd need an RN and maybe more to be seeing urgent visits and seeing patients if I'm doing longer procedures and all that, your needs really shift with what you do.
And then on the other end of the spectrum, if you look at models like Parsley Health, which are very functional medicine driven, and they're really consultants. They don't want you to call them if you've got a sinus infection, especially not if it's midnight on Saturday. And we always knew that we wanted to be very much a primary care practice, that all of our patients, whether they are mostly in California and only want to know we exist, if they think they have pneumonia when they're here visiting on the island, or our patients have got multiple comorbidities and are ill a lot, we wanted to be open for business for them.
And so that's part of why we want someone at the front desk, why I'm on call 24 7, except for my new colleague in Kauai, we're working out some call exchanges, which are great to be able to really take a vacation. But yeah, we feel like we can't just close down. So yeah, when we go on vacation, even if we're up in your trail ranch where there is no cell service for a week, that's what our staff is for.
Like we're still open Monday to Friday, nine to five. And we have to have somebody answering the phone for us after hours because that's what we're selling is true primary care We aren't just consultants. We do the functional medicine type work with the patients who want to have that, but we're also taking care of people when their sinus is hurt and their heart failure is out of control and all of that.
And it's so important to talk about because there is a difference. In the access that patients have under a DPC model versus fee for service or another type of clinic. So absolutely. It's so important to highlight that. Now, when you talk about being on call 24 seven, and right now you're talking with another physician on Kauai doing DPC to work out a coverage for both of both clinics, how has it been so far on vacation?
You explained the situation at the Muir trail ranch with no internet. And I'm laughing over here. Cause I'm like. Uh huh. That's why I have a device that operates in the Verizon tower, the Xfinity tower and the AT& T tower. So depending on what, depending on what elevation I'm at, certain services work. So people who practice really can really understand that.
I appreciate that. But when you talk about the vacation in particular, being on call 24 seven, how has that impacted your ability to enjoy vacation or your ability to sleep? Cause you mentioned not really having sleep was not something you were a fan of. When you chose to let the OB part go. Yes. And I'll answer it with two sub answers.
And the first is even when I was covering for our big community health center, I was amazed at how rarely people bug their doctors. in Hawaii. Now, maybe that's a Hawaii thing and maybe that's a big island thing, but that has certainly carried over here. People had warned me, Oh, you're going to have a bunch of privilege, rich people.
They're going to be calling you every time they have a hangout. Absolutely untrue. People are incredibly sensitive about our time and our family time. They can be having a heart attack and they're apologizing for calling me at 7 30 because, you know, we might still be at the dinner table. People are incredibly conscientious about that.
And I would say, again, we have a smaller practice, so with the number in the low 300s, I might get one or two calls. in a typical week, sometimes zero, almost never more than two or three in a week. So for me, I don't mind that. I love being a doctor. And I also like being a hero. That's part of what appeals me about medicine.
So that's just my quirks. I don't mind having to step out from I mean, you know, I've taken calls from the slope of Mount Adams just recently for all kinds of things that for some people I think would be a real intrusion on their life. I like being able to help people out when they've got an acute problem, so I can handle that.
Now that said, so people need to know that about themselves when they choose how they're going to handle call and the size of their practice. That said, It does get in the way of either being fully immersed with my family, which is important to me when I'm with my kids, and being fully experiencing time off and especially a vacation.
So that is a downer. It's never felt like a deal breaker or the number one problem in my professional life. But it's not ideal that if I'm on the mainland visiting friends that I'm, I still have to be answering the phone if my patient has a problem. It's probably going to only happen zero to one times in the course of a long weekend on the mainland, and I can deal with it, but it just doesn't mean a part of my brain is always turned on to that professional part of my life.
And that's not completely healthy. So certainly whenever there's the option to find a way to share call. Again, starting a practice with your wife or spouse is not the ticket to call Sharon because we're almost always together with our kids. So it's been, it would have been ideal to have an established DPC practice or cash pay practice.
Somebody who doesn't take insurance, doesn't need to bill Medicare, et cetera. who was already on this island that could have shared patients with me in a way that was not intimidating for patient stealing and all of that. It just isn't what we had. So I've been shouldering that load with my wife and Kauai obviously is not ideal either because my patient thinks they have pneumonia.
We can't get a stethoscope on a patient here on the big island from Kauai, but they can still handle prescriptions. And I don't need to tell you, most of the medicine can be done virtually these days. And it's such a great point again to highlight because it is a realistic, a realistic thing to experience in DPC, especially if you are a solo physician in your practice and something that like the California DPC collective has done the.
DPC California syndicate as we're called on Facebook is we've organized. Thank you to Dr. Fiedler in the Bay Area. We've organized a, who is willing to take call? What are your rates? Are you just exchanging to take call for other people? And that's something to look into, especially if you're just starting out or if you haven't thought about it and you'd like to take a vacation or if an emergency comes up, like who's your list of contacts and in what order would you contact them?
And the other thing too, is to think about. Does your malpractice cover locum's days so that someone can be covered when they're covering your practice? My malpractice has 30 days of locum's coverage per calendar year. And so that's something that you could ask if you are in the middle of choosing a malpractice insurance company.
Yeah. It's something that I was warned about often in my conversations before starting DPC is be careful not to promise the moon. Unless you really want to deliver it, and that's just one of those things everybody wants to build access because that I mean, I'm sorry. Everybody wants to pitch access because that is part of what we offer in DPC.
And if you want to be given all your patients, your cell phone number, then just make sure that you want to be answering your cell phone at all times. And if not, then. It's important to come up with a creative solution. Fortunately, it's one of the great things about DPC and why we do it is because you have a predictable income that allows you to take two weeks off to see your family on the mainland and not make less money for those two weeks.
You just need to figure out a way so that your patients feel like their care is not being compromised. It's totally doable, but they just need to know they're going to talk to a human being. They're not going to have a terrible interruption in their care. And that they're going to want to stay in your practice, fully understanding that they don't want you to be chained to your office 365 days a year.
Cause it's not good for you. Yeah. And as I'm on the cusp of taking our first true vacation, since the pandemic happened with all four of us in our family, it's quite incredible that my patients echo what you've, what you just shared and that they're like, that is awesome. Like you totally deserve a break.
And like how, where are you going? I mean, Like we are doing our part to make sure that refills are done for the calling physician that they don't have to take care of the stuff that could have been done before vacation for us. But I think that's so important in general. What happens to your patients in terms of their care 24 7?
Is it you? Is it another person? And what happens when you open and you. What and what you promise them when you open does matter. Yeah, it's important not to over promise as tempting as it is because everybody is worried about failing to fill their practice, not making it financially. So very tempting to offer everything you can think of, but it's need to only offer the things you really want to provide for the next few decades.
Awesome. So now I want to go into your practice name because you guys are, your clinic is Iris Integrative Health. And so how did you come to choose that name in particular? That was perhaps the most painful of all the painful processes because we just never could come up with a name that we liked. And it was getting to the point where we had to pick something.
And we got in this very abstract tangent of. Okay, I'm a conventionally trained doctor. You're a naturopathic doctor. So we're kind of bridging these worlds and our office is right where the rainy side of town meets the dry side of town and there's rainbows there because of that and Iris is the Greek and Latin for rainbow and When it takes that long to explain your naming story, you know It's not a strong name and we've known it wasn't good when Isis came about It's not good every April when people are paying the IRS their taxes.
It's just thankfully it did not submarine our practice and it works. But boy, I don't, I love your name. You've got a great name. We just, we don't have big trees here to name a practice after. Oh, man, as you're cracking me up, I appreciate you sharing that story. And I think it's, I'm sure that there are other listeners just laughing because that's probably very realistic in terms of experience for other people as they're choosing their name, because especially as DPC.
grows. The amazing clinic names like Insight or Paradigm or Olive Leaf or whatever, they, these names have been taken. And it's so interesting to hear the backstory, but I really appreciate you sharing the pain behind that. Cause again, I'm sure people can relate as they're listening. Oh, it's got to be like trying to write a fresh and new rock and roll song in 2022.
Like people been doing this for a long time. They've stolen all the good hooks by now. Oh man. So hopefully a little bit easier of a question in terms of the integrative part of your practice. When you have two physicians who are coming together as husband and wife and Onboarding a new patient, the person who found your practice online and who has never seen you before, how do you find out what type of care that patient is leaning more towards?
Our staff asked them, it's really as simple as that, because some people, they want to see my wife, they don't want to see me, other people want to see me, have no interest in naturopathic care, and some are intrigued by having a naturopathic physician on board, or maybe they have a few issues they would want to run by her, or they're more comfortable doing their women's health care, reproductive care, with a woman than a man.
So, the whole idea is we just have to ask and make sure that we're not in a situation where somebody's seen the wrong doctor on their first visit. Gotcha. And in terms of the care that you guys highlight on your website, I want to highlight this copy in particular, because I loved it. It said, whether you have interest in dance or cooking classes, regular exercise groups, or nutrition for diabetes, we can offer these without extra charges.
We can even accommodate house calls when the need arises and the schedule allows. So When I read that, I wanted to ask how, what has manifested in the past that led to that copy in particular? That was something that felt like an important and exciting aspect of this practice when we birthed the practice, because that seemed like such a great way to translate some of the more staid and uninspiring aspects of medicine into what can really affect people's health.
If you can get them excited about cooking real food, if you can get them excited about being outside, moving their bodies, these are ways that can really transform people's lives. Now, the reality is the pandemic put all that to a grinding halt and also to some degree, our success really cooled our Our interest in coming up with the extra time for offering activities like that.
That's the sort of thing again that when you're excited about trying to get a project off the ground. It was very enlivening to imagine. Yes, doing cooking classes and taking people on hikes. And no, we did and have done that sort of thing. But when it becomes like, okay, our practice is full, we have a wait list, we just need to take good care of the patients we already have.
It's really easy to back burner those things. So we talk about that periodically. I want to get a group going, maybe even for non members. Because I'm feeling that sense of I'm really not giving enough back to the community these days. So all that still gets kicked around, but that sort of thing can be a victim of success sometimes, because you get busier as your practice fills, and you just, the number one thing is always providing really good medical care.
That said, we do still offer house calls. That feels important for our patients. Our little newborns in the first couple months to keep them out of the office, and patients who are injured, patients who have impaired mobility, That's a really nice thing to have the time to be able to block off two hours at the end of the day to make a house call for a patient that at least if they don't live an hour out of the way to be able to come and really see them in their own setting.
Absolutely. And on that, I want to ask about the procedures because some of these procedures you might do at a patient's home, but in terms of when you were open, you know, in fee for service, as well as your DPC now, what types of materials do you think a future DPC doctor should consider? Specifically because of the location of being in Hawaii in terms of equipment or in terms of cellular service or whatever, you know, works best and unique for your geographic location.
I was pleasantly surprised by how inexpensive the stocking of the office part of that equation was. Obviously you can go. fancy and really want to provide a lot of services and get yourself an ultrasound machine and make sure you can read it. Some people offer cosmetics as part of a value added thing.
You can do all this stuff that involves a big startup cost. But for us, I feel like it's been fine with some real basics. You know, an EKG machine is inexpensive. A little Doppler for finding a fetal heart rate is inexpensive. Most people still have, you know, one of the most expensive things is just a good otoscope.
But most people still have theirs from med school. I really I think we only had to invest once we were done outfitting our office, which because there was some remodeling involved, then you're talking five digits, but I think everything else was really just a few thousand dollars of pretty common sensical stuff.
But again, we kept it low tech. And, you know, the sort of procedures that I do are, if someone happens to cut themselves on an office day, I'll absolutely stitch them up. I love that stuff as an ER doc, we'll do skin biopsies and skin procedures. every now and then put a cast or a splint on somebody when they need it.
But we're not a procedure heavy practice. And that again, unlike you probably we've got a hospital more or less across the street that has got orthopedists and surgeons that are, I just know they're going to do a better job than me at cutting out some massive sebaceous cysts or a podiatrist can pull out a toenail better than I can do.
I mean, I've done all that stuff, but I've just come to realize my limitations that if I'm not doing it all the time, it's better to let the pros handle it. Yeah, but you nailed it in terms of the nearest hospitals 45 minutes away and the nearest level two traumas an hour and a half away. So absolutely it's, it differs depending on where you are and something to think about it in terms of when you're choosing resources, tools in your clinic, or making contacts with people who can provide the care that a patient might need if you were unable to provide that type of service at your clinic.
So, Amazing. It's been incredible speaking with you today and hearing your experience from the state of Hawaii. And so thank you again for sharing what you have. And I wanted to ask just one more question in terms of, do you have any other words you'd like to share with the audience in closing? I will say that I always loved being a physician.
So I'm not one of those people who went to med school and then regretted it. I wanted to be a family doctor in a rural setting from the get go. And there is still literally nothing else in the world I would rather do. That said, I think I was on that burnout slope, working in a busy community health center, and then trying to swing it on my own in private practice as a fee for service doctor, and it was professionally consuming.
So, I would never discourage someone who's thinking about going into medicine from going to med school and practicing primary care just because a lot of people are disenchanted with what happens to their careers once they get in a big hospital in practice or an HMO plan or a community health center.
Because. If that happens to you and it turns out that it's not for you and burnout is on the horizon, knowing that this option exists, I think can really help justify that very hard choice to invest all the time and money in medical training. Because if it turns out that It is too consuming and the love of practicing medicine fades because of the demands of the job.
That is a great opportunity to take the skills that you've mastered in the years of serving your community as a insurance accepting physician, to take those skills and see what else you can offer in a model that lets you give more of your time to each patient. It's out there and it. Can be done and can make a huge difference in the quality of your life and the quality of your professional practice.
And, and one of the things that that's brought to me in the flexibility that having a lighter schedule allows is I now take every Tuesday morning and I write about medicine. And I love that because a part of me always wanted to have a bit more outreach than just my own community of patients and everyone in the family, right?
So that seems like I probably ought to as well. So to have the time to devote 4 or 5 hours every Tuesday morning to researching a new subject and writing a sub stack about it. I love how that changes my sense of knowledge of the field and what I'm doing professionally. And there's just, there's absolutely no way I could have had the time and resources to do this in my old life as a fee for service physician.
So I really appreciate that there is this ability to do a great job caring for patients and do a little bit more in terms of self care or investment in family time. or feeding your own professional interests. And it's really possible for most people who like to get eight hours of sleep a night if they're trying to care for 2000 patients.
Thank you so much, Dr. Hollander for joining us today. It was great. I really enjoyed it, Mary Ellen. And I'm just glad that you're doing this. It's a huge resource for a lot of people.
Next, we look forward to hearing from Dr. Peter Cascio of Code One Concierge in Austin, Texas. 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 DPC. Leave a five star review on Apple Podcasts 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 Check out dpcnews. com until next week, this is Mariel Conception.
*Transcript generated by AI so please forgive errors.