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Episode 143: Dr. Peter Cashio (He/Him) of Code 1 Concierge Care - Austin, TX

Updated: Sep 18, 2023

Direct Primary Care Doctor

Dr. Peter Cashio of Code 1 Concierge Care
Dr. Peter Cashio

Discover the journey of Dr. Peter Cashio, a dedicated emergency medicine physician, and advocate for veterans' health. Born in Louisiana and raised in Houston, Texas, Dr. Cashio's path to medicine was shaped by his early years as a U.S. Marine Corps intelligence analyst, stationed in diverse locations such as Virginia Beach, Virginia, Okinawa, Japan, and Camp Pendleton, California.

After his honorable service in the Marine Corps, Dr. Cashio pursued a passion for biology, earning his undergraduate degree from the University of Texas at Austin in 2000. He continued his academic journey, achieving a Master of Science in Developmental Biology at MD Anderson Cancer Center, UT Houston, in 2005. Driven by a desire to make a difference in patient care, he embarked on his medical education at UT Health Science Center, San Antonio, ultimately becoming a licensed physician.

Dr. Cashio's commitment to excellence in emergency medicine led him to complete his residency training at the prestigious University of Virginia Hospital in Charlottesville, Virginia, in 2012. He is proud to be recognized as board-certified by the American Board of Emergency Medicine.

In his medical practice, Dr. Cashio firmly believes in the importance of listening to his patients. He follows the age-old adage that "listen long enough, and the patient will describe their diagnosis." This patient-centric approach forms the cornerstone of his care philosophy, allowing him to provide personalized and compassionate healthcare.

Dr. Cashio's professional interests encompass a wide range of medical fields, including preventative care, men's health, pain management, and critical care. However, he holds a special place in his heart for veterans' healthcare needs and is dedicated to serving those who have served our country.

Outside the office, Dr. Cashio balances his life with a passion for powerlifting, a pursuit of aviation knowledge, and a flair for writing. With his family residing in Dripping Springs, he finds inspiration in the beauty of his surroundings.

Experience healthcare from a physician who understands the value of time and the importance of each patient's unique story. Dr. Peter Cashio is here to support your health journey, combining expertise, compassion, and a commitment to your well-being.


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14101 US 290, Suite 400B, Austin, TX 78737, 1/2 mile south of 290 & Sawyer Ranch Rd

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Direct primary care is an innovative, alternative path to insurance driven healthcare. Typically a patient pays their doctor a low monthly membership and in return builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the My DPC Story podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model.

I'm your host, Marielle Concepcion, family physician, DPC owner, and former Fee for Service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care. Direct. Primary care.

DVC means, uh, having a relationship with the patient where you actually understand them from the start to finish. You understand their nuances, their struggles, the things that they're going to want to do, the things that they will never do, their social situation, family, friends, parents, and that way, when you see them, you understand that they're not just a person with a problem.

They're a person who is a husband or a father or a mother or a daughter, and all these things are at play. And so when you're trying to treat them, you're able to see them as the whole as. Part of their social and cultural and I think it delivers better care people and get people and they love that. I actually listen.

So I'm Dr. Peter cashier's code 1 concierge. And this is my story.

Dr. Peter Cashio was born in Louisiana, but moved to Houston, Texas at the age of six. Shortly after graduating high school, he enlisted in the U. S. Marine Corps as an intelligence analyst and was stationed in Virginia Beach, Virginia, Okinawa, Japan, and Camp Pendleton, California. Following the Marine Corps, he went on to complete his undergraduate degree in biology at the University of Texas at Austin in 2000, a Master of Science in Developmental Biology at MD Anderson Cancer Center, UT Houston in 2005, and medical school at UT Health Science Center, San Antonio.

He completed residency training in emergency medicine at the University of Virginia Hospital, Charlottesville, Virginia in 2012, and is board certified by the American Board of Emergency Medicine. His care philosophy revolves around the idea that the only way to understand a person is to give each person the time necessary to tell their story.

He practices by the old medical school saying, listen long enough and the patient will describe their diagnosis. His professional interests include preventative care, Men's health, pain management, critical care, and especially care for veterans. His family lives in Dripping Springs, and when not in the office, you can find him powerlifting, learning to fly, and writing.

Welcome to the podcast. Dr. Cashio. Hi, Mariel.

How are you? Glad to be here. I'm, I'm doing great. I am coming off of weekend where fellow California DPC doctors and myself went to the California Academy of Family Practice resident meetings, medical student meeting, like update on our, you know, do you prescribe vitamin D, do you check for vitamin D, that, that type of.

Meeting where what, what you said in your intro is so important and that's, I feel what really got people who came to our table, some of them were current program directors, I will put a shout out there for them who are asking more about DPC, not only to have resources, because we've created this Cali DPC dot com, where if you're wanting to know more and connect with California specific, uh, DPC doctors, there's a whole listing of us, So it does not only have that as a known resource, but to also say like, now I want to know about DPC because I, that, that's the type of medicine that I signed up to go to medical school for.

So I really love that, you know, your opening statement is just really a great representation of the relationship based medicine that we all do in DPC.

Yeah, I've said that has been the biggest, biggest revelation for me starting this clinic.

So one of the things that I had seen on your social media platform, and I love it because it's like, you know, it's, it's you and your clinic and all different aspects of your clinic are being highlighted, but occasionally you'll like turn the camera on yourself and you'll do some, some talking about your clinic.

And I just wanted to get started with thinking of a space where you are a physician. You're a DPC physician now and your experience being a veteran and being a Marine. So you went on to talk about in this one particular video, we never promised you a rose garden. And you said, you said in that video.

That doing things that are focused, disciplined types of work daily. That was the kicker there. Daily will get you to your goals faster than anything else. So I want to go back now with that quote on the table from your social media and ask about. What does focus discipline work mean to you from your past before you became a DPC doctor?

Yeah, so prior to that, it was, you know, for example, young guys, young Marines or young potential recruits say, I'm going to be a Marine. They have this vision of the uniforms, sexy uniforms, gorgeous women going to wash blowing things up, doing cool, exciting things. And then you get to infantry school, which we do a very abbreviated version, which is why I didn't abbreviate version and it's, it's, we call it the suck because you're climbing mountains.

It's cold. It's wet. You're checking head spaces and machine gun. You're doing all this stuff that is not sexy. It's not fun and but it's absolutely necessary. And, you know, you have your sergeants every day saying. It doesn't matter. You need to do it. Right. You know, vigilance saves your life and the lives of those around you.

And you know, so I, we, I really learned that no matter how glorious it is, sometimes when things are glorious, right. You have to put in the work every single day to get to that point. Otherwise you're going to harm yourself or harm others. Right. So that's kind of how I, when I brought into medical school, when I brought into ER doctor, the DPC doctor.

Fantastic. Fantastic. And I think that. You know, as we get into our chat today, I think that people will hear from your discipline as well as the repeated reminder of how discipline can work in your favor will come through in, in what we're talking about. So bring us to, you're an emergency room physician and you are, you're doing your thing in the ER.

What on earth made you even think about DPC?

I have to be honest, most of our physicians, I can't speak for family medicine, but most of our physicians have this experience in the 3rd and 4th years of medical school, where you do rotation after rotation. And for a little while, you say, wow, I could be a family medicine doctor.

I could be an OBGYN. I could do psych. I could do and then you reach a point where you're like, no, not really not not sustained. And then it's like, oh, yeah, right. And so most of your physicians go into emergency medicine to do the big, sexy things to do whatever to be a master of many things and critical care resuscitations are strong suit.

The reality is, is a lot of emergency medicine is my blood sugar is high. My cholesterol is high. My blood pressure is up and my doctor sent me to the ER where my doctor is not there. And I would hear horror over the, so I did, I've done emergency medicine over a decade, 12 years at this point, and I would hear story after story about primary care doctors, you know, so called abandoning patients.

And, you know, as a physician, sometimes you're like, you take it with a grain of salt, right? People have their perceptions that may not always be true, but it became a theme over and over and some of the struggles in emergency medicine are, you know, you have these big corporate emergency medicine groups that are Like ER doctors are a commodity.

You can be replaced at a moment's notice. There is no loyalty. You're 30 patients a shift, and it doesn't matter if there's a critical, you know, you're resuscitating a critical person or code, like a code, you still get patients screaming at you. Like, well, they haven't seen a doctor in 30 minutes and they don't care.

Right. So it's a lot of burnout. So I was reaching the point where I thought I can't do this because I actually care about humans and being, taking three minutes to have a conversation. Blood sugar management gets you yelled at by the clipboard, you know, Armada in the ER saying, I'm sorry, Dr. Castro, but you need to go see more patients.

So, I'm sure I've heard from you guys in family medicine, it's a similar thing, you just have no time. So, I, it's just like, I can't do this. Uh, and then even if we're put into impossible situations, like psychosocial, medical, legal situations, that there is no good arisma. Talked to a friend of mine, Michael Garrett, who's another ER doctor, direct primary care, yeah, love Michael.

And, uh, I think I had posted on the DPC group and Mike said, hey, I'm close when you come by and visit my clinic and this isn't like 2019. And he said, after a couple of visits, he's like, dude, you can do this. I was terrified. And he's like, no, just take it easy and take it slow and you can do this. You're smart enough.

You're a board certified ER doctor. You can learn it, but just take it, take your time. So I opened up in January of 2020, the pandemic hit, and so that was brutal. But about 18 months later, I left the ER full time and started growing my clinic because again, just being back in the ER part time was just soul sucking.

Well, especially as you described that, you know, it's very interesting because, you know, When you're saying, you know, as an ER physician, you see the full scope of things. You just see it from a different level of acuity than a family doctor. A family doctor typically sees it in outpatient clinic. But you know, when, when you're talking also about the similarities between your professions or specialties when it comes to like, and I don't seem to have any autonomy in determining my schedule or the quality of which I will put into every single patient visit, because you're on the clock.

Like I remember Dr. James Gore, another emergency physician who has now become A DPC physician working with his wife, Emily, at Halcyon Health, um, Dr. Emily Scott, he said, you know, the, the number one thing is what is your insurance? It's not like what brings you in today. And also, you know, it's so similar to the frustrations of like the dumpster fires that we get on our plates and the dumpster fires, because it's like, Well, because you didn't have access to your doctor who knows you when you needed them, you guys are like the stopgap.

It's like, great. No one in this community has a position. Go to the ER for any little thing. And it's like, you know, I remember, I think I've mentioned this on the podcast, standing there in the emergency room, check in area for my own son when we were there for tachypnea. And I was like. Hearing, you know, in the background, Well, the urgent care told me to come here because my blood pressure is 150 over 90, and that's a medical emergency.

Or like, Well, I have this red thing on my face, and that means I need a CT scan right now. And it was like... Oh, boy. And then versus, you know, I think about even today, as I'm sure you have, it's like, well, today, those types of acute questions that came along my plate already before we started recording this podcast, I was able to get back to that patient, you know, because we're not seeing 4000 patients on our panel, because we know our patients.

Because we know their hesitancies to take medication or not, you know, all of those things. It's like, that's why we do this. I love it. So, as you went into the space of Dr. Garrett saying, you know, take it easy and take it slow. What did that translate to in terms of you actively opening your DPC? Because I know you mentioned during the pandemic, but you're also winding your time down from what you were doing in the ER to go to DPC.

Yeah, so, you know, my biggest fear was, um, that I, who was I to, you know, imposter syndrome, who am I to pretend I Who am I? Right? What Michael Garrett suggested was, you know, get 1 type of just take a patient as they come to where you feel comfortable. So, what do you do for mixed type? What do you do for new onset hypertension?

What do you do? And you start to just learn and read, uh, such that , you know, and accumulate 600 UpToDate credits in a year. After a while, you get more and more comfortable reach out to people and you say, Hey, what do you do in the sticky situation? So you get more and more comfortable. So that, that, that first year I might have had 60 patients and if, you know, I see a lot of folks posting in the D P C.

Forms on Facebook, how they opened and they had 500 or 300 and that's great. But from where I started, that would have been overwhelming and something probably would have been missed. So, but about 18 months in, I started getting a lot more comfortable and I realized, as you sort of alluded to, that a lot of the complaints are the same, not sounding like they're critically ill ones, but you don't need to go crazy.

And so it's like finding that, that, oh, this is, oh, this is clinic patients. So that population is by nature, generally less sick. In my population, just where I'm located is less than a grant. So, those are lessons you learn for residency in medical school.

Yeah, and let me ask you there because you mentioned up to date and that's a great resource that we have available to us as physicians, but I would love if you could speak to.

The fact that like you're going into there with also a medical degree, there was a physician's assistant who I spoke with who was talking about how they went into what they thought was a physician's assistant role, but because of the model of where that corporation was in providing care to patients. A lot more was put on that patient's or that PA's plate.

So can you speak to, you know, the difference between a physician doing things like I've had a ton of time, like knowing what's normal and knowing like what to do in acute situations, plus adding on up to date to that because I'm asking because I'd love if you could speak to the fact that like you can't learn to be a doctor up to date, you can enhance what you have.

Oh, for sure. Yeah. Yeah, so, I mean, so my background now, I was a Marine and then I went to college and then I went to graduate school. I got a genetics degree, a master's in genetics, and then I went to medical school. And so. You know, like I say, I like to joke that I graduated from the 27th grade and when you had a residency, and so, you know, everything I've learned in medicine and so me, my experience was.

I've done critical care medicine, you know, what do they say? We do over 10, 000 hours of residency at least. In terms, like, such that I'm not a brag, but any resident, any resident in their 2nd year on an rotation can handle just about any emergency by themselves. They don't need to like, freak out. For the most part, they can handle intubation.

They can handle airway management, pressures, pressors, arrhythmias, that kind of stuff and you become very comfortable. And so when I became an ER, I tried to open a DPC clinic. It was like, okay, where's my critical care and lots of. Thousands and a decade of being an ER physician, and now I'm going to learn an additional skill set.

Right? Whereas. You know, I, the I've seen are generally better trained in keys, but if we want to open that can of worms. It's kind of horrifying, and when I used to be an ER physician down in Corpus Christi a couple years ago, there was an NP training program at Texas A& M University, and we would get these brand new NP graduates who had literally just graduated in May, and now they're working the summer.

And they're terrified, and they're wearing the white coat, and I would say, okay guys, You don't know anything you loan less than nothing. Your training sucked. I'm sorry to tell you that being said, if you're open to training, I will work with you come to me and we'll start to talk the Socratic method.

Right? Like. You know, if you're going to present to me, there are X age patient with the following medical conditions presenting for chief complaint of block. And why do we do that? Because it stretches your mind to think, oh, what questions do I need to ask? Or what did I forget to, what am I going to need to order, right?

Or to evaluate this patient. And so I think that it's really, it's a fault of our system that we think that we can replace physicians with literally thousands of, I probably have 20, hours at this point. I'm not bragging, but if you count medical school, medical school residency, clinical practice. And I'm still like, I tell my patients, I don't know everything.

I can't possibly know everything. So, if you have a different opinion where you read something, bring it up. I've learned from my patients, my nurses, my staff, and sometimes I see students will come along. They think you can't teach them anything and they're dangerous. But I think, you know, the training is not great.

And so I don't know where you want to go from that. But, you know, there's a lot that you could talk about in that you sharing, you know, your experience and what you've seen out there, because when direct primary care clinics are out there and. You know, for on places like, uh, the MAPR where you can't necessarily see the difference between physician led clinic and a non physician led clinic.

I think that's important for people to know. And I, it's important for their physicians to hear as well because, you know, physicians, like there was a group of 90 physicians I, I was reading a story of that they got replaced, you know, their hospitalist group, it wasn't ER physicians, but hospitalist group got replaced by non physicians.

And, you know, it's like ER is definitely a place where that's happening, where there might not be a physician on site. During, you know, a shift or whatever. And so I think it's really important for not only physicians who are like us attendings, but also for the people in medical school and residency to hear because no matter what, do not forget your value as a physician.

I think that's so important for people because, you know, as we're doing things like, what else can I do other than what I've been doing, you know, or what else can I do other than what I've been seeing? And you're thinking about DPC, it is very important to never forget how important your training is and how important the thousands of hours, like you said, 10, 000, the baseline I use when I'm talking to people is minimum 15, 000 hours that we have as trained physicians to be able to know what's normal and to know what's not.

And so, you know, I, I put that out as a word of encouragement for those who are like, I'm already overwhelmed with what am I going to do with my career? Should I do DPC? Do I even matter? Yes, you do. Yes, you do. So that said, now, when you were making the change, when you said you, you know, you had 60 patients in your first year, one of the things that you had had talked about also in your social media was, was growth, growth of your practice and growth, just the growth mindset.

So you shared that a mentor had asked you. And I don't know if this is Michael Garrett or not. No, it's a different mentor. Okay, yeah, yeah. Uh, and you know exactly what I'm about to ask. Uh, that mentor said, Are you in DPC or are you just playing? And soon after you went from 60 patients, uh, 66 was what you had in the summer of 21, if I am quoting that correctly, to 188 by December 21.

So, can you share about like, How did you receive that comment and how, how did you, how did you think about growth differently after that comment was made to you?

It's a great question and thanks for asking it. Um, for those who know me well, um, the best way to get to motivate me is to tell me I can't do something, right?

To call me out and like, are you just, are you just, whatever, right? Oh, you'll never be a Marine. I heard that one. You'll never go to college. I heard that one. You'll never, who are you to go to graduate school and get a research paper published? Et cetera, et cetera, et cetera, et cetera. And every, like, every time it was like that scene from Google hunting, right?

And he slaps the girl's phone number on the window and it's like, how do you like them apples? Right. That's kind of my motto software day. And so my, that mentor, she's a great lady. She, oh, she knew it. And she called me out on it, got mad. I really got mad at her, but she was right. And so I was like, okay, fine.

If I'm going to do it, what does that mean? That's a lot of local networking. It's actually not so much networking. Just social media, like Instagram, Facebook posts in my local groups and also general Facebook and just making connections with people that has been, that's, that's what's helped me grow. And I kind of, I'm a little over 200 now, and I kind of stopped because.

I do so much. I provide such a level of care that I feel like I can't handle anymore now that we have another physician coming on later this year. And now that there's somebody to cover all my off days and vice versa, so I don't feel so like, I'm going to leave my patients. So we're doing it. We're ramping up again.

We're doing the website. We've got social media marketing plan already set up and we're just going to start talking and talking and talking. And it's a slow game for those who might be listening. Social media rarely is a, I do the post and all of a sudden I get 5 people sign up. It doesn't work that way.

Right? It's, you know, the idea of a long tail. So you do all these things and you build this body of work and you get overnight success. Months later, or a year later, I have people joining my practice now who saw social media posts from a year ago and they're like, I kept you in mind and this is the time now I'm ready.

And the other thing I would tell people. Is if you're going to push pushing the late summer early fall, because people are thinking about a new doctor for January 1st. And then the other thing I would tell people is that you need to do a really good job of explaining DPC. So, to be fair, I chose concierge because people can wrap their mind around that.

But when you say DPC, people are stuck in this mindset of. Well, I either have insurance and so therefore I have a doctor, or I don't have insurance and I have no access. And when I tell them in the E. R. out in the world, you know, that does not that those 2, those are not the only 2 options you can pay. You know, some places are as low as 70 dollars a month around here.

You have a doctor. That's your doctor.

What? Absolutely I'm like, here nodding my head because, like, my Lyft driver who drove me. From my, like, bachelorette day at Disneyland, like, I had, like, a few hours at Disney California Adventure, but back to the airport to fly back to Sacramento, I was like, I tell all of my Lyft and Uber drivers about DPC, but I was like, yeah, you know, like.

You know, and then I, you know, segue into how in hell do I talk about DPC to every single person? There's always a way. There's always a way and everybody understands the pain of like how you're saying, you know, you might have an insurance card and you might have a doctor, but when are you actually, actually going to see that doctor?

And do you see that doctor every single time you go into the clinic? Probably the answer is like, no, no, no, no, like to every, what is the benefit of having a primary care doctor or primary care providing doctor on your insurance card if you can't actually access them for primary care and you have to go to the ER anyways.

And then when you talk about the people who are like, no, but I'm uninsured, undocumented, it's like, and we don't care because we are a human being. So that's what matters to us. I mean, we're not going into veterinary medicine here. Not yet. That's another whole other pod. But the other thing too, is it. When, when you're talking about when people understand finances, especially an Uber and Lyft driver, because they're working for rides and they're like, wait a minute, like, you're telling me no matter what I could have a doctor for me that knows me that is accessible when I need them and like, you know, how many conversations have ended in like, You, wait, you said there was someone local who, who is that?

And I was like, well, here, HalcyonHealthDPC. com. There you go. And then, you know, so it's so awesome when people do get that like click in their heads and, you know, people being potential patients, you know, potential physicians who are thinking about DPC, potential people who are benefits advisors, building DPC into self funded plans.

It goes over everybody. When you get to like, what is the value proposition that we're bringing? Mind blowing shouldn't be mind blowing because you know, it's not new what we're doing in terms of this is how people used to be before hmos, but it's like When everything is about magical specialty care.

Well, well, your, your insurance companies have a bigger marketing budget that we do that has set the mind of my patient. So I have now probably 10 patients who have what they described to me is, uh, you know, triple A gold plated or platinum, whatever health care insurance and they're my patients. And every single 1 of them, they're like, well, I was like, so what brings you here today?

Why did you join? I have the greatest insurance. I can't find a doctor. Like, nobody's taking patients or I can't see my doctor for 3 months or I, you know, like, I have this doctor and they never listen to me. I've got my PA telling me what my results are, but I haven't actually talked to the doctor in a year.

I haven't seen the doctor in a year. Right and so I'm just like, and so how is that working out for you? So it's an emotional investment 1st, right? It's I always tell people who listen and listen. I said, look, it's almost like you're getting married. Right? Because people invest so much of their hopes. And expectations and like, maybe this doctor will be the 1, right?

And that's why people don't just join up right away. Most of them, some do. It takes them a while. They're like, you know, what if? Because even though the cost may not be much, the emotional investment in choosing a doctor is a big deal, right? And so I always tell people that. And then, you know. For those who are financially minded, I said, so you pay through the marketplace 12 to 1800 a month for insurance.

Did you know that there's a way if your family, depending on your family's needs, like there are these things called health shares that work really well and you can be paying as low as 400 or 500 for your family and like for catastrophic care and you can get a PPC doctor. It blows them away.

It totally does. Totally does. You know, a couple things like just going back to when you were mentioning how like, you know, it might not be initially that somebody signs up one. I think that's why word of mouth really helps our practices because it's like, oh, I already emotionally know you. You're my best friend next door or whatever.

And it's like, and that's your doctor. Like, I'm in like what I like. I trust you and I know you and I know you know me and you wouldn't be talking to me about this if it wouldn't help me too. So that's one thing. And then two, when you were mentioning that it takes time for people to, you know, know that you exist on social media and then follow you, like, see what you're doing, and then potentially that leads to a membership.

It's the same way even for Physicians, I had a physician reach out who saw my post from two years ago, like that is what this physician quoted on my own page talking about direct primary care. And literally the question was, so I saw this post that you did two years ago and it just it sat in my head.

This whole time as I did, job that sucked, job that sucked, job that sucked. And so, you know, can you tell me a little bit more about it? So I say that because especially like, as you mentioned, you know, we're going to talk about how you're adding a new doctor this October, but like that, that stuff matters.

Like it really does matter not only for patient membership, but also to grow your practice in terms of the physicians who are joining you. I mean, if you want to segue into that, I mean, we can, um, because that is a perfect example of how I ended up with this new physician. So his name is Dr. Zach Patrick.

He's an ER physician like me. And I met him at my 1st ER job in 2012. Uh, we worked our 1st job together out of residency, and I love him to death. And he, for a long time, I thought he was the opposite of everything I was, but we're close friends ever since. And, you know, I told him a couple of years ago in 2019 that I was going to open a DPC practice.

He's like, wait, what's that? And I explained it. He's like, you're crazy. And then he came out to my, he came out to visit my practice. So just FYI, this is my additional building. So we have 2 buildings that we have now that I got my office over here. We were just in the original space and I, it was micro practice.

I had no help really. And he hadn't, he's been talking to me over the years and his frustration with emergency has gotten worse and worse and worse. Basically the smartest, most caring guys I've ever known, right? And so last fall, he says, so, hey, Pete, how's your practice going? And I said, why don't you come check it out and we'll talk.

And this is like, last a year ago. Right? So, he comes out and he sees our other, you know, other building, other campuses, like, well, what happened there? And I said, well, we've got bigger and we have these additional providers, non medical providers that, you know, need space. And we have this whole holistic thing where, you know, kind of, oh, you need a trainer.

You can talk to our trainer over here. You need nutrition. It's all right here. You know, you don't have to go anywhere. Is for the geographics of my city, and I'm in dripping Springs, Texas. Awesome summer people don't want to go to be above the junction of this highway. 71 to 290. it's a horrible traffic mess.

Right? So, if you can provide that service locally, it's an excellent quality. They'll do it. Right? And so he's just really blown away and he's like, okay, so how do you make it worse? Show me your numbers. Here we go. And so we agreed in principle about a month ago that he was going to join the practice and that my birthday party recently, he came and we sat for hours talking and like, 2 days later or some driver at my neighbor.

Look at the house. Like, he's all right. If I could find a house, I'm buying and he's serious. So we're agreed. We know what's happening. And I'm like, are you sure about this? He's like, dude, like. He's like, no joke. If you can do it, I can do it. That's the attitude, right?

Absolutely. And what an amazing birthday present.

Like I would take that birthday present any day.

I get to work with a friend, you know, and he's even more chronic, he's really crunchy granola. So it'll be a nice addition, a little nice balance to the clinic practice. And, you know, the patients are super excited. I've mentioned it, you know, unofficially to a couple of them.

They just love seeing the practice grow. They, you know, they like to see the success because it It's validation for them that they made the right choice. Right. And then I'm not going anywhere.

Definitely. And that, that's a huge thing. You know, like when, even when I was in fee for service, the number one question that I would get from my patients, especially those who are older, was like, are you planning on staying?

Like, there's such a PTSD from the patient side of things when it's like, here's a really great doctor, but the way that the system is killing them by, you know, soul sucking their job satisfaction out, not providing messages every night. Yeah. It's like there are multiple dumpster fires going on in the U.

S. healthcare system, and that, unfortunately, is a question that patients have as a result of that, of the multiple burning fire, uh, dumpster fires, but when it comes to growth, because, you know, you started talking about how your clinic grew, this mentored, you know, set off that like pissed off fire in you, and you're like, I'll show you, but when it comes to growth, and now that you're growing with a new physician, you Can you touch more on how to strategically grow because like, you know, when you're going even from that 60 ish to almost 200 and there's some people out there who are like opening with 200 or going, you know, to 600 patients in a year and that's a shout out to Dr. Ashley Hendry and Mid South DPC. Yeah. But when you're, when you think about growth, do you have any advice as to how to grow the clinic, depending on, you know, you might have two kids, you might have no kids, you might be married, you might not be, but how would you have people think about growth in terms of still maintaining quality access to care as well as your own, you know, maintaining your own autonomy and your own time away from practice that you need?

That's a great question. Probably the most important question. It's a conversation I have all time with some of my colleagues. So, the answer, the 1st question you have to ask is like, what kind of primary care doctor do I want to be? Shout out to Vince Lassie. He'll do it. He'll do YouTube a, you know, doing a vasectomy and I'm like, all right, let's get after it.

Right? I may have done it in residency, which. By the way, I will never be doing those things, but you know, this, you know, he's fearless, right? He'll do all these things and he probably charges a lower price, but that's okay. I just decided that I was tired of being burnt out. And so I said, this is how I want to work.

And this is the level of that I want to make. And so I basically designed the life that I want to have just as a background. I'm a single dad. I have my kids from the divorce. I'm recently divorced and a couple years ago. I have custody. So I am I'm a father. And so I need to be there for my kids and that, you know, something at 1st, it really irritated me to be honest, because I'm like, I really would, if I didn't have kids can really blow this up.

But long term, who cares? Right? Your kids are more important. And your kids will be pissed if you weren't there for that important thing. And I would be sad that I missed it because I missed a lot as an ER doctor. So why replicate that? So I had to decide what kind of lifetime and, you know, what kind of availability would I have, right?

Am I available 24 7? Nope. Very upfront. Am I available on the weekends for emergencies? Sure. Right. But if it's something I can wait, that's fine. And patients generally are very good with that. And so with that in mind, I'm very upfront about, you know, I'm more accessible than any doctor you've ever had. I see some of the young doctors saying, well, I said 24 7, but really I don't want to be available 20 percent of them.

Just be honest about it. Like don't hide it. But say, I will be, and you will be more responsive and more caring than any physician that they've ever had in the story. And if you are, if they don't like it, they're mad. Then Doug says, be well, right? Have a great life. Right? And then, and again, depending where you're at, pricing is important.

So Josh will say a lot about pricing. I agree to a point, but then I've learned that people, the more we charge them, the more they value what I provide. So, if I'm charging you 65 a month, you just don't care. I'm just, I'm a medication prescription refill guy. That's all I am. And that's the reality. Right?

But if I charge you more, and that more is varied over the years, then people, we really, they'll listen, they'll pay attention that they tend to because they're having to put what to them as a decent chunk of change down. So, I'm going to listen to the doctor because I'm paying for his expert advice.

So for the listeners here, this is a definitely a DPC moment, prime example of why it is so important to know about DPC and to like in our cases, Dr. Cash's and mine, um, to do it, to jump into it because he had to take a break between recording sessions to go and pick up his kids. So family comes first and now the podcast.

So thank you so much, Dr. Cash for coming back in a different office and joining us again today.

Happy to be back. Thanks for having me again.

So where we were talking, we left off talking about growth. And one of the things that I wanted to ask was, as you, you know, look to October, you look to next month, a month from when we're recording, you're about to bring on another physician.

And so I wanted to ask about, you mentioned earlier how you, 200 because that's, that's the place where you found that You know, you could still be a quality doctor, be the dad that you wanted to be, be, you know, the person that you need to be apart from those two roles. How do you advise other people to think about growth when it's not just coming down to the numbers in your practice?

Well, so you have to ask yourself, what is the growth for? What's your reason, right? Are you looking to make as much money as you can? What is your life situation? If you're a single person like out of residency and maybe you're married, but you have no kids. Like, go ahead and go, go crazy. Right. But if you're like me, single dad with custody and you also, you want to be present and there's a, there's a limit to what you can do.

Like I said before, I think I'm the 1st part if I in an ideal world, I would have 5 or 600 patients to begin with and I wouldn't have to do anything. But that is a level of service. That I, the way I provide service that I can't actually do, it just becomes overwhelming. In fact, actually it led to a burnout situation.

So what happened is I get to about 200, 180 to 200 and it's kind of stayed there because would just have been inundated. I feel now I understand a little bit of what a primary care physician has or feels goes through where it's like, not portal message, but texts and emails and oh my God, I have this crisis and oh my God, I need this form out, form filled out and oh my God, can you see me today?

Hmm. And why not? And it just never ends. And so what I was able to do is I was listening, reading some accounts from these old doctors, like doctors who grew up in the 60s and And, uh, they said, you know, I would have my nurse look at get all the results and get all the things and just kind of go through and highlight what was abnormal and show me the abnormals and then everything else just got forwarded to the patients.

And I would follow up when I had time and it just blew my mind. I was like, Oh, my God. So I happen to have 2 part time nurses who are smart and good. And I said, can we do this? We start this process where you see this and they did. They love it. They're engaged. And so getting that process involved, where if the lab results come back and you don't see the abnormalities, they can just send to the patient and I'll follow up with my email.

If they get an x ray and they want to know what the result is, here it is. Dr. Cashio will follow up. If it's an abnormal one, you know, he'll be, he'll be right behind me with the abnormals. So for me, it was getting the processes because you can't make more time. There's only so much time that you have. So for me, growth was.

How do I maximize the time? How do I free up time for patient care? And now that I have got the processes and I'm actually ready to grow and then bring in another physician on board, I can say to this new physician, here are the processes which will save you time and keep you from getting buried by all this crap that drives us all crazy.

And on the other side is, you know, patient expectations. Do not expect me unless it's a critical result to be calling you at night with the result or to be on the weekend like we'll get them to you and you know, just setting good expectations that people are very happy like they're very happy

with those limits.

And like you said, you know, at the end of the day, the quality of care that you're offering, even, you know, working through those processes. is still a very different experience than they've ever had before. And that's why they continue to be your members. And so, you know, when we talk about workflows and processes, I think that that's where the value comes in.

So if you're newly listening to this podcast, listen, just like, you know, you mentioned how you listened to the words, you read the words of physicians who would do like primary care for a long time and have these processes where like they were employing their staff to help them get through these processes.

you can do whatever works for you. So like in, in our practice, you know, I've gotten to the point where sometimes there's so many things going on on my plate that I'm like, okay, we have a HIPAA compliant place where we can leave voice messages back and forth in the backend. And I have our nurse say like, these are the portal messages that I need answers for.

And then because of, you know, this is so not surprising to people that I, you know, I'm an audio learner because it's a podcast, but it's like, I'll be, you know, speaking back in a voice message in our platform. Like, okay. So for patient one, do this patient to do this patient three, ask them this question or whatever.

And it still gets me to the, you know, accessibility goal that I have during the end of the day, but it's in a different way than I ever could do in fee for service. So I love that you mentioned, you know, how you were working through your own processes. And I hope that those words are very helpful for people, especially as they're growing or even planning on opening.

By the way, you just taught me something, by the way. Well, I can dictate a note and it'll look at my platform and have my nurse follow up on it. It's a lot easier. Very nice. Thanks.

Awesome. I'm happy to help. Yeah, I just, man, it's, it's so nice when you have an entrepreneurial brain about you added to the doctor brain about you and you're like, Whoa, I can actually like do things.

Without having to have some admin approve my workflow, you know, it's, it's so freeing. So let me go back to your building because now you have a new, newer space because you're building a whole center where you mentioned, you know, like if you need a physical fitness trainer, if you need a nutritionist, you're looking to have a true medical home for your patients so that they don't have to cross that freeway.

For you, bring us back to when you were looking for space because some people open with no space like myself. Some people open with. Spaces based on, you know, their proximity to their home. How did you go about finding a space?

Well, I wanted some place that was close to home. So I didn't want to have to commute.

I wanted to be able I knew that I had to get my kids to and from school. I wanted someplace that would not add a burden and I was looking for simple. I'm a big believer in the kiss principle, right? Keep it simple, stupid. If you were things that I have to worry about, uh, or would be costly to me, the better, you know, and I, to be honest, I kind of prayed about it.

I'm like, okay, there's all these options in my area, you know, look at some, you know, there's a brand new, which has turned out to be a very expensive, but very profitable, you know, retail park right, right next to my, my home, my development, but it's ridiculously expensive triple net and it is very. Yeah.

Like the people who are business owners, I know we're in space, they hate it now. I'm like, Oh, it didn't do that. So I found a space that I thought was pretty good. I got creative. I lowered my expectations, which was my patients need to have the fanciest office you could ever imagine. And I'm watching people through like DPC docs on Facebook.

Like you don't need much. I was like, I guess I don't. Okay. So, I met with the, uh, owner of, uh, the local business park and I had told her what I was doing and what my mission was. And she just, you could just see her get so excited. She's like, oh, my God. Yes, we'll figure it out. She actually, like, cut, like, gave me basically 10, 000 in credit and did it pro bono.

She's like, we're going to do this and we're going to set up your space like this and we're ready to expand. Let me know. Like, I want this to be your, your home. Right. And it's worked out really well. They're very good to us. But for me, what I found is yes, indeed, when I had 800 square feet and that was it for everything, my patients don't care.

I, this isn't a brag, but to give people who are thinking about DPC and what they think their patients want versus what they actually want. I have several multi multi millionaire clients, patients, like you just, if you're saying their name, you would know it. And I have a nice but humble, you know, office space and I have a nice but humble exam room.

And they, they don't care, doesn't matter to them at all. It looks clean. It's professionally done, you know, I decorated it. So go me. And at the day, they don't care. They don't need the fancy bling bling, you know, with bringing your poodle in and there needs to be a watering bowl. Like, they don't need that.

They don't like they. Just know your people and know that the care that you, I, you will give them, that I give them or whomever is listening, that matters to them like 10 times more than the environment. Obviously, make it clean and blah, blah, blah. But you can make it look like a home. I think I saw pictures of Doug Farago's clinic and it looked like somebody's living room.

I'm like, oh, that's cool. Right. And some other ones are really fancy schmancy. Somebody, I can't remember who has. Like their office space, like you can see outside there's trees and there's windows everywhere. It's gorgeous. Right. Um, I wish I knew who that was, but anyway, like, so it's just like, let your office space kind of reflect your personality.

I love that. And if you really talk to, you know, especially those people who are thinking about it or planning DBC, or even people who are like wanting to just get a, you know, just an infusion of. inspiration talk to DPC owners around you because it's really quite amazing how when you're talking about like people who have the money to have a doctor fly to them, they still choose direct primary care because it's not the office that most people are signing up for.

I mean, we're talking, I would estimate, you know, over 90 percent of the people could give a crap about where you're practicing, as long as it's safe. Like that's, that's a big thing. But you know, when it comes to, I signed up for my doctor to take care of me and my doctor who knows me to take care of me.

And that is what, you know, never, never forget that. And I just went to a home visit this morning. And that's what I used to do. I used to do all home visits and telemedicine and I, I forgot my bag this morning. So to go back and grab it because my husband on the day that we're recording, he started DPC and I was like, Oh my God, I need to like, make sure he has a stethoscope and I have a stethoscope because we're working at different times.

But it was like, you know, they didn't care that I rolled up with a bag like, you know, they, they cared because I showed up as the doctor who would be able to talk to them about their problems. Yeah. post hospitalization. So, you know, it's, it's so true what you say that like, there's not signing up. Our patients are not signing up because of the, the physical spaces.

Although if you have beautiful ones, like again, I, I call out Dr. Brian Blank and Ember Modern Medicine in Greenville, South Carolina. It's absolutely gorgeous. And I love that his patients have that. I, I would go there and be a patient if I lived in South Carolina, but it's not a necessity. No,

and I think, you know, to riff on that briefly, I think the reason that we might think that's important is because if you're in the traditional system, the system sucks, you know, there's this thing.

Well, I can't compensate with much, but we can make it look pretty. I mean, we're not plastic surgeons, so, you know, but shout out to the plastic surgeon hearing this, like, yeah, you have a certain thing you have to, you know, aesthetic you need to adhere to, but you're right. Like, you don't have, like, as long as your care is great.

And then later, if you get some money and you do really well, and you really want to have it up, then go for it. Right. But as long as it's not impacting the patients, they don't care. And

you know, because this is before Black Friday that this is gonna come out too. If there is something that you're like, I would love to have this, but I just don't need it today.

But it also could be on sale for Black Friday. Like I have a list going. That's like every Black Friday, I look for these particular things. And like, for me, I moved into a space last October and I wanted to have this like 1980s bathroom not look like it was from the eighties. And so I used contact paper that I got online on Black Friday for like way cheaper than it normally is.

And you know, it's, it was just contact paper, but it sure as heck made a difference in the aesthetics of my clinic. And I'm like so happy with it. So, you know, just another, another random tip, if you hadn't heard that one from me before. Yeah. So now tell us about when you were, you know, adding your new physician and you're opening up a larger space, at what point did you decide that was going to be the right decision for you?

And how did you strategically plan that space, given that your dream for Code One Concierge is different today than when you started?

Yeah. Strategic planning. No, I mean, so that implies that I was a deep thinker about it. So first of all, I identified the need and then I identified, I just listened to what my patients were saying.

I really hate going X. I really need to get a hold of Y, but I can never get a hold of Y. And I'm like, okay. And I don't know if I told you this in the first part of the podcast, but there's a psychologist. He's a friend of mine who, when I mentioned, I really want somebody that someone can is, you know, as somebody who could do therapy and he's like, I can do it.

He kicked me out of my office and I'd go into the lab area and work. It's fine. I don't care. So I already knew that like patients were fine with that and they were already seeing in there. I'm like, okay, well if that model works, what cheap space can I find that's gonna help? Right? And I talked to the, the owner of the business park that I'm at.

I'm like, Hey, here's what I'm thinking. They're like, you can have the space right next door. They're moving out and we'll give it to you for dirt cheap and we'll even help you modify it. And so I've got that counselor. I got the 2nd counselor. I've got hopefully a 3rd 1 coming. We're probably gonna do physical massage or acupuncture or something like that.

Other space. And there's Academy in space where we're about ready to do Academy infusions for mental health. So I've got the counselors in place. So how did I do it? I said, here's the need and if patients are already coming to me, how can I provide that space to them? That service to them? So that they, it reinforces my brand.

And so I get read. I don't take at 1st. I thought, well, do I ask for a percentage of revenue? And I got into this like skeezy, like I didn't, as I first started thinking about it, I was like, Oh, that's like, I'm working for this corporate medical group and they are billing thousands of my name and give me a dollar in return.

That's the same. I'm like, no, I'm not going to be that way. So, but I rent the space out. And what's, what's nice is that my patient's like, Oh, Dr. Cashio, he's the guy. He has all the people either right there. They're in 5 minutes and you can get ahold of them. It's not. And so. It was just, that was the thing.

And also I wanted a gym to work out that was right next door. So I would have no excuse not to work out, you know, it's evolved into someplace that's like a mental health facility or mental health campus more than anything right now. So, and now having another, and I also thought ahead, like, if I want another position, where can I put them?

Like, you know, now we have room over there. We have an actual exam room. So, if in 18 months, we have time now, we need a 3rd position, which might be happening then. You know, we already have a space already set up and code one takes over everything and then we're just, we're not more space or at least more space that we can move all our mental health people into.

So it's hope that answered your question.

Absolutely. And as you talk about, you know, second physician, possibly even third physician coming, tell me about how agreements are working. Are they 10 99? How are they being brought into code one?

So I heard a, I heard a phrase today that I think resonates, and I've had a conversation with Nicole Hemkes and Vince Lassie and Josh Umbera about all these things.

There is a founders get paid and employees get a salary and it sounds harsh, but reality is, is that, you know, this is something that it's my vision and I'm doing it. And so, but I don't want to take advantage of the positions that are coming on board. I don't want to do that. But I also recognize that I'm providing you with the space.

I'm providing you with processes and personnel and all this stuff. And so, but plan is, and we're finalizing his contract is going to be 1099. Thank you. And either like a 50, 50 or 60, 40, like 50 or 60 percent of his revenue that he generates. The rest comes back to the clinic, right? To pay for salaries and overhead and everything else.

And then I as the founder and quarter like making sure everything runs, we'll get a small percentage of that. And I think that works, right? It gives him agency. Like you eat what you kill. The more people you get, the more money you make. And you don't have to worry about anything. Right. You know, and I think this is reality is that not everybody's an entrepreneur now.

Not everybody wants to take the risk. Like, for them, the risk might be leaving my fee for service practice with 401k and all these benefits, but I'm seeing 20, 30 patients a day. And I've got, you know, practice managers breathing down my neck. But I might go to be a 1099 and not have as many benefits, but more capital at the end, more cash at the end of the month than I did this.

And I'm also my quality of life's better. It's a trade off, right?

Absolutely. That's what I think is also very helpful for people to hear, especially, you know, again, coming off of this weekend where I was talking to medical students and residents and program directors and all these people who are really learning about that direct primary care exists.

And there are so many DPCs in the nation that that's, that's an option. Like who I just mentioned earlier, Dr. Brian Blank in South Carolina, like, they're looking for a physician. So it's like, especially if you are, you know, Hey, I, I'm not tied to any particular location. I don't have kids. I don't have a spouse, whatever, like, I don't care where I practice, but I'd love to do DPC.

There's a lot of opportunities out there. And then, you know, code one concierges might be adding their third and fourth position. So it's definitely a thing now to work with. a DPC clinic that is already open.

Yeah. Yeah. And I think the, the, the benefit to that is that I'm sure you could tell, like, if you see, the old saying is, if you see one DPC, you've seen one DPC.

Right. And in other words, for the people who aren't doing this, like they might both say, might say to themselves, like, what does that even mean? Right. And that means that everyone has their own way of doing things and processes that are dependent on location, practice patterns, EMRs, unfortunately, fortunately, you know, and dictates a practice pattern.

And so you have to figure out what, what style suits you, right? And who you are, like, you know, for anybody that's coming on the practice owner takes a lot of risk in building the networks. But, you know, maybe this position is coming on adds as value out as 2 X, whatever he's getting paid. And then maybe later we do a partnership or some sort of agreement.

I'm okay with that. Right? I always try to be a team player and we all win together. If someone's taken advantage of someone else, I don't, I don't wanna do that. So, yeah, rambling and I love that, you know, when you're talking about things, you're, you're really underlying all of that is transparency. And, you know, I've, I've had people reach out to talk about like, how do I talk to so-and-so about joining their practice?

And it's like, well, you know, one of the things is we work in a transparent space. Like our membership is X amount of dollars per month or per year, whatever, whatever it is. It's the same thing, like if you would like to be part of this transparent world, then, you know, say like, I'm making this much at this job.

Like, I would love to make this amount, but realistically like to make my life continue with the, you know, lifestyle that I have right now to put food on the table for my kids. Like, this is what I'm looking for is that, how could that be possible? Is it possible like, you know, talk transparently because especially like.

When we talk about being relationship based doctors and we're, we're in this for the long haul when you have a partner join you. I mean, it's not, it's not expected to be a short term thing. And so having those transparent talks, like you don't have to agree on everything, but dang, when it comes to. being able to work together, that definitely leads to less, you know, resentment, hostility chances in the future.

So I definitely would encourage people who are looking to join just, you know, think about it from that transparent spot as well. Yeah.

And that's funny because it's been a couple of months since I was back in the ER, but there is not the reflex of just be open and honest with your patients in that world, right?

It's always like, we're going to keep this veil between you and me. We're going to keep this veil of like what's going on behind the scenes. You know, for medical legal reasons or whatever, right? Like, and what I tell my patients straight up is I don't know everything. I will never lie to you. I will hide it from you have a question or you have a concern, just tell me and if I, if the reverse is true, like.

Hey, I'm worried that you might be an alcoholic. No, I'm not. Everyone drinks like that. Well, this is why, right? And we just had these conversations. And as long as you know, like people know that you're coming from a place of honesty, you never have to worry about what you said. You don't have to worry about, you know, again, it's just easier.

It's psychologically easier to be open and transparent. So if there's somebody who's looking to join a DTC practice and the practice will not ever won't tell this is what we make. Okay. And this is what the numbers are walk away. Let's just don't talk yourself into it because it seems like a great deal, but it isn't.

Ever. Absolutely. I just, I think of a, somebody sent me a Doximity message that was like, work, like Doc Hollywood in this rural town called Arnold, California. And I'm like, that's where my practice is. That's hilarious. And they're like, $300,000 sign-on bonus. And like, it was very absolutely draped in a veil of like, who are you talking about?

Like, we only got two big corporations in there. And I left one. Like, what, which one are you talking about? And so 300. Oh my God. Oh yeah. I, I was like, That speaks a lot to the desperation of care in places. So anyways, let me ask you now about the people who've joined your practice. When you opened, because you said you, you know, you, you opened with those initial 60 and then you grew, how many of your patients are individual or family patients versus how many of your patients are coming to you through an employer?

I only have about 10 patients that are employed. These are all individuals and I'm actually, I just hired a marketing person. Or I want them that we want to go after the employer market because that's a really good way to grow. And in fact, 1 of my new patients, he and the guy who referred him last month, we're both relatively new.

They both own huge corporations and so they want to have the conversation about, can you do what you do? For all these other for all of our employees, I'm like, yeah, so it's mostly individuals and families that we may change to corporations. And again, it's for me, it's just been a, a bandwidth issue. And honestly, like, I think chain Purcell is, I believe he's in South Carolina.

He does that really well. And so I think that's how we really grow. And luckily, where I live, there's a lot of small to medium companies that really need. As I'm sure you can tell, it's just, they don't even know what it's, what it's involved. Like, what does that even mean? It's so true. And it's coming from both sides of the relationship with employers.

And when I say that, I mean, the people who are typically the brokers who have sold book a plans to people for level funded. healthcare plans and then the doctors who are, you know, doing this. And so, um, I will put a shout out to Rosetta Fest. I was very grateful to have co emceed that, uh, last month in Chicago where, you know, over 750 people who were registered are working in the space of how do we grow DPC with employers?

So, you know, employers from. 27 employees to over 300, 000 employees. And that is an annual event that happens every year. So I definitely encourage physicians to go because it's a great place to network with people who are in that space. Exactly where they're like, we have employees. We have the employers.

We just don't know where the DPCs are. And it's like, yes, there are mappers and things like that, but it's like, there is definitely a need for people who are physicians to say like, Hey, I I'm, I'm over here in the Austin area. I know you have employers over there because it's not like my neck of the woods when there's, you know, we're.

An hour and a half from the nearest target. So I love that, you know, you're talking about this potential space because it definitely is a space that has a ton of potential. And, you know, it doesn't have to be that you can only work with employers that have like thousands of employees. It's like If you make a difference in the lives of 27 people who work for the auto mechanic, that's amazing.

And then they're going to tell their neighbors, their friends, and then there's that more word of mouth. Right. So tell me now, when you're talking though, about hiring a person to help market your practice to employers, what's the strategy there? What are, what are you thinking about as the value proposition that you'd like the marketing person to help get out there in the community?

Yeah. So it's challenging. And I think the way that we're approaching it, we've tried it before. Someone who is a traditional, like, you know, drumming up business for, you know, specialist type clinics and it didn't work so well. And I'm not sure why, but I think this time my marketing strategist is we're talking about.

I think what I'd like to do is work with these two new patients who have these large corporations and say, Hey, I would like to, after you had some more experience, can we perform, do some video marketing, like do some videos, you know, and I'd like to go in person and talk to their companies and say, or whatever, like group of other employers and say, here's what we can offer you.

Here's what is possible to get some other people to help us. And then use those videos and these talks, right. You know, record me giving a talk. And then use that in sort of video retargeting ads. Like, Hey, are you an employer looking for affordable health care or health coverage for your employees? Is absenteeism crushing you, right?

Are you getting crushed with, you know, your, you know, out of pocket? You know, I'm the one guy who owns a very large company here. Let's say he's got about very large, but multiple millions over a hundred employees. We talked about how much he pays every month for his personal investment. In premiums and I said, it's like, 000.

I don't, I'm not the guy to do this. I know someone who does a shout out to New York, but I will say that there is a way to do this with a level funded plan where you can recoup most of that drive your, your month to month cost down, decrease absenteeism. And then if the money isn't left over in the year, it just comes back to you guys to use it.

He's like, what, what, this is a thing. This is a very successful business, but never heard of it. I'm like, this is one of my challenges is to learn more about this because when I talk to guys like near here, I saw the talk of the DPC, uh, that the meetup in Minneapolis, I felt like someone was speaking stereo instructions and I was like, okay, I don't really understand what's going on, but I need to learn more.

So that's going to be the focus this next year is to make sure we get more employers. Well, hopefully I'll see you at Rosetta Fest next year. But I will put a shout out also to Nir though, because Nir and his wife, Dr. Katrina Iqbal from DirectMed, um, were also mentioned, Michael Garrett, that's awesome.

They were on the podcast, I want to say in like the, maybe episode 26. So definitely take a listen to their episode. But Nir gives a great. Just, you know, a primer on like, what's a level funded plan? What's a self funded plan, et cetera, et cetera. So it is definitely new, you know, terminology, but so is opening a business and getting an LLC or an S corp or whatever.

And we did those things. So hard things are doable. So, so you can totally learn.

Yeah, and here's the guy who helped me get the current company that we have, they reached out to me wanting to solve a problem. And I said, well, had you heard about this kind of thing we just talked about? And the lady called me said, what?

That's a thing. I'm like, yeah, it's a thing. She started asking a lot of technical questions. And I said, let me send you over to near that. I didn't hear anything for about 2 months. And then boom, NIR's like, Hey Pete, we're going to sign them up and here's what we do. So shout out to NIR, uh, it worked, right?

And they're happy so far. They're really happy.

Love it. Now, when it comes to your training, initially as an ER physician, now turned DPC doctor with those ER skills, you know, under your belt, I want to ask, you know, cause it's it's different for like me as a family doctor, I worked in the ER. during residency.

Very different experience than what you lived for years, right? So when you talk about that you are an ER trained physician and you're a DPC doctor, what are the things that you would very frequently see in the ER that could be more acute level type stuff that you handle in your DPC practice? because you're an ER trained doctor.

And what things should people think about if they're like, I totally want to make sure that I offer acute type care in my clinic. What are the things that you recommend people either have on hand or look into for beefing up their skills to be able to be confident to provide that care? Fracture management.

It's a good one. As long as it's not an open fracture, you should be able to manage that in the clinic. Even if you don't have imaging, it doesn't matter if you can see like a radial, just a radius fracture. Foot fracture, you know, whatever, you can often do a hematoma block, which if you don't know what YouTube is great for that, you don't know what to do and then you split it and then you can get them rapid follow up or you can, then you can send them to the imaging to get a static X ray and they'll love you for it.

Blasteration repair know what the good which lacerations are appropriate for your clinic and your skill and comfort level. Know which ones need to be referred out. Minor burns, again, know, know the indications for which needs proper burn management, burn care. Not everything needs to go to the ER, or not everything needs to go to a burn center, but some things do.

So usually it's, you know, hands crossing the creases, face, genitals, certainly BSA depends. And that's also a local practice pattern. If you have a burn center in your town, They may say, sure, we'll see them or hey, you can give them a call and they'll follow up with the patient on 2 or 3 days giving infusions.

I'm plus minus on that for my patients. I'm okay with, you know, they're having issues and they need to resuscitate, like, get a leader fluid. Both of my nurses have either got critical care or are training turns out I can do it. I'd be. You don't want me doing IVs because eventually you're going to get infiltration or you're bruising.

It's a horror show, but I can do it right. So if you're micro practice and you're comfortable starting IVs, I would learn that skill, learn how to start an IV, learn how to do phlebotomy if you want to, you know, save your patients a trip to the lab and now they're, if you don't use like lab, I don't know how lab quest, I We use Central Pathology Laboratory, CPL, here in Central Texas.

They don't really provide you any supplies. You have to pay for it yourself, so it can be expensive. But, if, like some companies, like Access Medical Labs, where they fly it to Florida, and they do it, and they give you the results in 48 hours, they provide you all the supplies that you need, so you can learn how to do labs.

We did that, I did that for the first 6 to 8 months, and my patients... Loved being able to come do that. So that's 1 thing you can do. What else foreign body removal, depending on where it is, you know, learn how to get things out of the eyes and nose the years. I'm trying to think. So, you know, abscess management.

Oh, yeah, abscess management's a big 1. Like, don't be afraid to Lance of oil. You don't need to be a surgeon to plan some oil. It just depends on what you're experiencing. I've seen. People say, Oh, I'm sorry. The hospital say the surgeon needs to console and do an abscess. And you're like, come on, really? But that's okay.

If that's what you're doing. So those are the basic skills I treat mostly adults. And so when I first opened the practice, I thought I would need a lot more meds. So I had a lot of injectable antibiotics like septoraxone and clindamycin. They rarely use them really just don't really need it because most of my patients have access and I just don't see that many critically ill.

I do keep PENGY because strep is the thing and usually if I say, Hey, would you like a shot today or 10 days of pills, they'll usually go for the shot because they just want to get it over with. Right. Um, so be comfortable doing that and being able to do it. If you are a doctor and you have a micro practice and you have never actually injected drugs once before, go get the nursing handbook, learn how to do it.

That will save you from doing things that I may have done when I first started. I then called my nurse practitioner friends and be like, What did I do? And they're like, you idiot. This is what you need to go do. So that's, that's the kind of stuff I would talk about.

I love it. And you know, I'm, I'm laughing over here.

Um, just in a, not that because the situation was funny, but just cause it was like only in DPC, man, I'm visiting Dr. Emily Scott and Dr. James Gore's practice in Irvine, California, Halcyon Health. And I'm sitting there like we working in their office. And then all of a sudden this, this mom comes in and she's like, My son was hit by a car.

No, he was run over by a car. And he's like literally a block away and no, no open fracture, no, no blood. But it was like, you know, she walked him into and James is there helping him walk into the clinic. And he's like, I'm an ER trained physician, man. I gotcha. So he's like, you know, doing this thing. He's calling the phone, calling his friends.

Like, Hey, I would like to get an X ray just to make sure, you know, he's doing okay, but like the kid has no worries about needing to follow up about concussion, about, you know, if there's, if there's something going on day after day, after day, as he heals, it was insane. I was like, how go figure, man. I'm like literally sitting here, like working on charts.

And then like in somebody else's DPC. And this is what happens like only in DPC, man. But I love it because, you know, when we talk about what are we actually doing? Some people ask, like, not only is this real, like you said to that, that lady, the employer asked you, but also like. So what, what do you do? Like I have this question.

Do you just like refer people out for everything? And so one of the things that I loved that I think it was on maybe your website was that you had your own laceration paper. And I, you know, I love that. It's like, Oh no. Like when you actually go to Dr. Cashio's site, he's like a real doctor.

I like to give a shout out to my friend, uh, Dr. Ben Silverberg at WVU. He's a family medicine trained guy. We met in residency. He, uh, reached out to me, like, two years ago, and he's like, hey, Pete, you want to be on a paper? I'm like, sure, right? Everything you said, and also the thing I would say is, um, have OPAs, oral pharyngeal airway, just a little curved C, uh, C thing that you can stick in someone's tongue if they ever have a seizure or they just have an airway issue.

I mean, you can get an AED, you don't need an AED, but if you have one, great. Another procedure is, if you can do an EKG in your office, do an EKG, if you know how to interpret them. And finally, have at least oral glucose Like cake frosting and have one dose or two doses of an injectable Benzo because I had a guy who had a seizure for the first time in my clinic.

Thankfully, my nurse was there and she's like, Hey, Dr. Cashio. I'm like, he's having a seizure, you know, and either was freaked out. Right? And we have what we needed, but I mean, it's not that I would use it that often. So, but, you know, those are some additional things I would have, you know, and then have 911 or just the 911 and, you know, make sure that.

Okay. If you're thinking about what to do procedure wise, is your, how close is the nearest EMS, you know, station from you? Like thankfully ours is within three minutes, so it's not a big

deal. Mine is at this moment in time, like across the street, so it's, it's, uh, it's pretty cool when you can have that access, even in rural America.

Dark Impressions, they call 911, yeah, yeah.

Oh my gosh, but no, like I think about it also when you're talking about maintaining an airway, I just, I think back to like when my son was, you know, to Kipnick and like, one thing I would say is Decadron, like we all have access to Decadron and we're getting into flu season.

Like that's definitely something that, you know, is. Pennies on the dollar, it's like $20 for the whole bottle. And you, you're given, you know, a kid, a little bit of that. And then I definitely would say, you know, things like you can, you don't have to buy an EpiPen, you can actually get epinephrine for pennies and you's dirt cheap.

Yeah, that's dirt cheap. So those are other things that like, you know, I found I would not wanna have this happen, but if it happened, these are the things that I would like to have. So, uh, you've dropped a ton of gems, so I love it. Learn how to inject joints, uh, knees. like steroid injections, right? The shoulders, knees, it's very useful.

Your patients will love you. They'll feel good, you know, just basic stuff. And I'm forgetting the author, but the big yellow procedures for family medicine doctors that I have on my shelf, really useful. You know, I think maybe that's where Vince last learned how to do his, uh, a kid, Vince, but it tells you how to do a vasectomy in there.

I'm like, okay, not doing this, but moving on. Those are all good things to have, you

know, so. Absolutely, and just for people who don't have that yet, uh, Feninger and Fowler's Procedures for Primary Care. That's it. Excellent, excellent, excellent book. You can buy it used, you can buy it new, but that is an absolute must, definitely for people who are doing procedures, but just for anybody who's doing DPC because it's a great reference for, you know, if you're practicing doing something, learning a new skill, um, it's it's an extra.

you know, resource to have that's quality, quality. Tell me how to remove an IUD out of that. Not something we do in the ER. Go to OB. Oh, no, I'm the, I'm your guy. Okay. I just, I shake my head at that because especially those of us who have been, you know, in the world of, of medicine for a while. It's like, there's things like that where it's like, seriously, seriously, that's what you did with your ER training.

Like, oh my gosh, I just, I shake my head at that.

Well, no, but the thing that if you are, especially if you're just getting started or thinking like DPC curious, your patients, because they trust you want, we'll want you to do just about everything. If I suspect, if I was a woman, I'd have a lot more, uh, GYN, right.

And just women are more comfortable doing that with their OB and that's fine. God bless them. Right. But I've had several shock, like, will you please take care of do all my well woman exactly. Okay. Right. And so they haven't established OBGYN. They just regret they like and trust you enough. So be prepared to do more than you're used to doing and fee for service.

And I definitely hear stories all the time. Like, I don't. I have an internal medicine. So it's totally doable. We do lots of things. Yeah. So now let me ask you there, when it comes to going back to your experience as a Marine and when you are talking about these processes before, when you are, Looking at, you know, doing everything like you, you know, when you opened, it was just you.

Now you're going to have physicians joining you. But when it comes to like inventory and workflows, when it comes to just learning from what you've been doing to see if it's, if it's, if it could be improved on you, you mentioned, I think this is back in like the, during the time you opened in 2020, where you had a video of yourself and you're like, you were talking about working out and how important it was, but you also said.

Every little thing you do has consequences. And so looking at your practice, when you see your workflows, when you see your inventory, when you see like the management of the everyday things that are separate from your medical degree, how would you talk to, you know, people from your experience as a Marine?

And how to best, you know, address the workflows of processes and make sure that they're continuing to work for your best practice. So, I don't know that the Marine Corps is the best. I mean, Marine Corps is good. We're not, people have an image of the Marine Corps Marines as being very regimented. Yeah, but the Marines as an assigner are very flexible.

Like, just get the mission done. Here are the parameters. Good luck to you. Actually, the best model for that is surgeons. If you've ever been in the OR and all of us who've been through medical school had been in the OR, you'll watch how the surgeon, how there's a flow. If you watch the, the instrument is to where he reaches out and then somebody puts it in his hand.

It's all about reducing your cognitive load, right? And so that sounds very fancy, but are you going to prefer, if you're going to set up an IVs, right? If you're going to set up an IV, Well, do you have everything you need right in front of you, or do you have to go back and forth and go back and forth and do so even when I only have an 800 script space.

I still have my two exam rooms. I have my lab room, which also had a lot of my extra supplies, you know, and so it was just like, oh, I have to go back and forth and back and forth. And it becomes frustrating because I have to think, oh, where's this thing? Where's that thing? And there's only so much think of the mental energy you have.

There's only a finite amount each day and you can increase it over time. But if you have to think where everything is and think, oh, I need to have this. Oh, I need to. Oh, crap. I forgot about that. And you're running back. You're going to drive yourself crazy. Your patients will be frustrated. Okay. So what I always tell people is like, it's easy to just start doing.

A lot of people just want to get going and they want to start and they just want to figure it out. It doesn't always work that way. Sometimes you need to, you need to stop and think, have quiet time and imagine yourself going through the different things. If you're going to do an EKG, what does that look like?

I wish I was in my office office and I could show you a video of how we have this procedure room now, which used to be my old office and we got, we have a big, you know, husky tool chest that we've turned in and I've got, I had set it up to where I thought it was going to work. And then I had my nurse come behind me and say, okay, Rebecca, now, is that how you would put things?

Or if not, why? And she was like, no, I would put these because I'm going to use these together. You're like, oh, okay. And so we've now had to do several procedures and everything, and the flow works, right? And it has to work for not just the person doing it, but for other people need to understand it. Right?

Or to another example of, okay, you're the patient and you're coming into your clinic or my clinic for the 1st time. How is that experience? When someone calls you after you've enrolled online, you don't talk to any of us. What is that experience like? My office manager Sandra calls and says, Hi, Mrs. Smith, we are so happy to have you.

Is everything okay? Did you have any questions? Okay, and here's a step, and there's a series of texts that they get and emails were very nice about like following up and then when they come in, Dr. Plotting, Plum Health guy. Sorry, forgetting his last name right now. You know, he, when people come into his office, like he stands there and greets them and says, Hello, we do that as much as we can.

You know, and it's like, would you like some coffee? Is there anything that we can get you? And then we said, you know, if you need to stop the interview and go, go to the restroom, please do that. Like I thought through this whole process when they have to go to the bathroom, where's the bathroom when they walk into the bathroom, is everything where they don't have to guess where things are.

It's seriously like, it's those little things that will save you so much friction, not only for yourself, but your patients too, because they don't have to guess. , right? So that takes a lot of mental effort, and it's hard, and you will constantly be refining it, but it's how, like these five star hotels, that's how they kick ass and take names because their hotel rooms are really no better than anybody else.

But it's the service, the thoughtfulness. So you need to be very thoughtful about what would you want as a, as a patient, what were the things that drive you crazy, but assuming that you have a doctor, Mr. DPC doctor, when you go to the doctor, what frustrates you? Do you have to sit in a waiting room with other people coughing into your, into your ears?

Totally. And you know, you mentioned the hotels, but like I mentioned earlier that I went to, you know, a few hours in Disneyland, it's like, what is the number one thing that you can expect to see at Disneyland at the front is like all the people with their tablets who are like, do you mind if I ask you a few questions about your visit today?

And then even after you go, you get it popping, popping up in your mailbox. Please fill out a guest survey about your recent experience at Disneyland. And so, you know, when it comes to just strategy is how to reflect somebody who very much love and respect Dr. Alison Edwards, she had talked about how, when it comes to even being able to ask our own patients, our patients.

you know, generally they want us to survive because if we survive, we continue to be their doctor. Our businesses don't shut down. And it's not common for DPCs to shut down. That's definitely a question that I get often. What Dr. Allison Edwards had mentioned was the Larry Green center person centered primary care measure.

And so that is a way that she's, that she spoke about. Being able to, you know, engage with your patients on a different level that actually matters because you're, you as the business owner asking your patients, like, how could I be better in addition to thinking like if I were my patient, Oh my gosh, now that patient who has knee osteoarthritis or Parkinson's tremor, when they came into the office, I definitely said to myself, like, these are the things that I would not do the next time or whatever.

And so if that means like. Taping down carpets or like you're saying, you know, making sure that things are accessible that people don't have to look for where's the toilet paper refill, you know, that it's really important, but that it also speaks to how individualized our clinics are, like how you're saying earlier, everyone looks different, but there are definitely ways to constantly, you know, improve and invest the time that you have reinvested back in your business.

And I would also make sure that people think about the processes, right? Like communications, you want to keep it simple by trying, and it doesn't always work. Humans are going to human, I say, but you know, I tell my patients, if there's a medical emergency, don't email me. I won't check it for 24 hours. And then, oops, you know, you're in trouble if it's an emergency or you're really concerned, it's urgent.

Text me. And then I said, through my office staff, but my office staff is very good about returning. You know, like. We're Johnny on the spot. We've even responded at 8 or 9 o'clock at night in some cases, not that anyone has to, but that's just the way we work. Right? And so, like, my patients really adapt to that.

And they're like, they know, they know it's not hard to get ahold of me. It's not hard to see me. It's not hard to. If nothing else, we have a nurse that will call them, right? So you want to think about, okay, they're paying you, but what does that experience look like? And then Doug Farago talked about this in his turnbook.

You're going to have to constantly raise the bar because then they'll become adapted to it and bored. And then it's like, well, what else have you done for me? Right? So you just, you know, the constant habit, like, okay. I'm going to make, we're going to bring the level, the level of what we do up a notch, right?

You know, that's unfortunate. That's just humanity, right? Like, you know, you want to keep it interesting and fresh.

Awesome. So now in closing, I want to ask if you can drop any additional words of inspiration or hope for those physicians out there who are like, Hmm, this is really inspiring. I really am still on the fence though, about doing DPC.

We're all dying at some or some rate, right? We're all going to die someday. Well, it's a fact of life and. You get to choose how you live your life, right? Like, if you are in a terrible situation at some point, you have chosen that, right? And I was telling a new patient today about, he's like, you know, I hate this thing that I do and I hate it.

I hate it. I'd rather be doing this. Yeah, but it makes a lot of money. I'm like, do you have enough money to walk away? He's like, yeah, I'm like, then this is your choice. So, all of us as physicians have the ability to live a good life, to live a far above average life if we choose, no matter what our circumstances are, right?

So, ultimately, you just have to get comfortable with being uncomfortable. If none of us went into med school knowing what we were going to do, any previous training or knowledge we had prior to going to med school probably got wiped away in the first six weeks. No kidding. Right? We're all just like, Oh my God.

And so we've all now gotten comfortable, even uncomfortable with a toxic relationship. Let's be real for most physicians, their, their medical practice environment is toxic. It's an abusive relationship. And so why are you doing it? Right? So you just have to get so sick of it that you're ready to change.

And then once you decide to change, it will eventually get better. You can do this. I'm a smart guy and my brilliant genius level. No, but a lot of DPC docs did it before me. How Mike Garrett showed me the way I'm like, okay, there's a lot of. Imposter syndrome at the beginning, like, who am I to be doing X? I will say this, like, I had a, my former marketing gal, I love her to death, heard me on a previous podcast, and she says, you know, you were referring people to different people, but they you're that good.

They should just come to you. You are that good. And I had to go. Oh. I get yes, you're right. You know, maybe mad, which means that she was telling the truth. So you will become good enough. You will become excellent enough. Embrace it as physicians. We are always so hard on each other and ourselves. We are, which is we, we're vicious and DPC is not like that.

And so. You could have a better life, but you have to choose it and you have to work for it. And it's not just going to be handed to you, but if you choose that way, then good luck. You will have a much better experience. And I can tell you today, like I actually love being a physician again, but when I, right before I started my DPC, I was like, no way I'm not ever going to like as hard as I worked and all the sacrifices I made, I quit.

And now I'm here and I'm like, I can't, this is what I do. And this is who I am.

So love it. Thank you so much, Dr. Cashio for joining us today. All right, guys.

Thank you so much, Mary Alice. Pleasure talking to you.

*Transcript generated by AI so please forgive errors.


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