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Episode 153: Dr. Concepcion & Dr. Beckenhauer Talk About Clinics, Patient Care, & DPC's Mission

Direct Primary Care Doctors



SUBCAPTION HEREEpisode 153: Dr. Amber Beckenhauer of The Healthy Human
Dr. Maryal Concepcion and Dr. Amber Beckenhauer

In today's episode, we have a special guest, Dr. Amber Beckenhauer of The Healthy Human, joining our host, Dr. Maryal Concepcion.


Dr. Beckenhauer shares her experiences and insights on building a direct primary care practice and the challenges they face in providing accessible and affordable healthcare.


We dive into topics such as clinic expansion, maintaining the mission of DPC, and the importance of patient experience.


We'll also hear heartwarming stories and get a sneak peek into the exciting plans for the upcoming year.


So grab your headphones and get ready for an insightful and inspiring conversation on My DPC Story Podcast!

 

Watch the Episode Here:



Listen to the Episode Here:



 

Here's a glimpse of what you'll learn:

  • Importance of Accessible Primary Care: Ensuring easy access and positive patient experience.

  • Challenge of Maintaining DPC Mission: Avoid falling back into old habits and traditional insurance models.

  • Growing and Improving the Practice: Reflection, patient input, and continuous evaluation for growth and enhancement.

  • Collaboration and Communication: The need for clinics to work together in providing quality care.

  • Financial Considerations in DPC: Balancing affordability and quality care in the DPC model.



LINKS/RECOMMENDED RESOURCES:

For the LATEST in DPC News: DPCNEWS.com

The Healthy Human Website: HERE

Big Trees MD Website: HERE


Check out the My DPC Story RESOURCE PAGE! Find a DPC checklist on how to start your own DPC, DPC conference recordings, and more!



CONTACT:

Contact Dr. Concepcion: HERE

Contact Dr. Beckenhauer: HERE



SOCIALS:

The Healthy Human: Facebook | Instagram | Twitter

Big Trees MD: Facebook | Instagram




EPISODES MENTIONED:





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Transcript*


Direct primary care is an innovative, alternative path to insurance driven healthcare. Typically, a patient pays their doctor a low monthly membership and, in return, builds a lasting relationship with their doctor and has their doctor available at the time. 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.


Hello!


Hey there, Cali, Nebraska sister.


This is so funny that we're doing this. We're recording a little bit earlier this year. I am very cognizant about if I get sick and if I lose my voice. And so I was like, yeah, let's record today. But Amber's on the other line with a, with a stagnant picture today. So I got the Calibraska.


She's got the Nebraska beauty going on there. So it's, it's super exciting to talk with you again.

Well, I always love coming on board and just getting to chat with you, I guess, more rofessionally, not just personally on the phone. And it's a great week to be doing this because, you know, we had thought about having this early to protect your voice and everything, and then also talked a little bit about Veterans Day and, and, you know, having just different things we do with our practices and specials and things like that, and I always love Veterans Day because my dad is a veteran and we just.


We're talking a second ago, Mariel and I, about juggling practices in life and prep. And that is definitely something this week I got a little bit of. That extra taste of not only having my own personal immediate family, my practice, but then having a parent be ill and in the hospital and have surgery and trying to help them navigate the complicated system through insurance and Medicare.


And so I got really a handful of things this week thrown at me and. It's made it a little bit more educational, I should say, but definitely a little bit tougher as well. But it gives us great insight to pass on to other people and hopefully help people guide their practices. So it's a great week to be doing this truly.


I'm glad. And as always, you know, I hope that your dad continues to be on the up and up. And it's pretty incredible if you haven't, you know, and you do know someone who is a vet, you know, it just, it makes me think about how. It can be really challenging sometimes in the veterans administration system for vets and like, especially in our area, it's not easy to access care because you have to drive a fair amount to get access to certain specialties or whatever, because we're so rural and, you know, thinking of veterans in who are in DPC practices, it just makes me very happy that they can.


You know, access the same high quality of care as any DPC member. And I wish then we'll talk about this later, but I wish that this could be a thing that veterans get period and not have to, you know, only rely on what they get from their VA benefits, um, going forward. Yeah. Yeah, I agree. I agree. So in, in talking about that, this is a good week.


What's going on clinically or what's going on, I guess, entrepreneurially for your, your business and everything that's going on at the healthy human.


Well, we have a lot of stuff going on. It is crazy. So right now, actively, as I'm sitting up here on the third floor of our new clinic, my husband is on the main floor painting one of the tops of the cabinets and making a nice little creative, unique wood top.


So that is going to look pretty fancy. I went and checked on him earlier. So that's, you know, just the reality of a DPC doctor for sure, especially one that's growing and building because it is a family effort for us and the growth is just kind of become, it's more organic, like we weren't planning to be where we are.


Uh, we have our site in Ashland, which is where I grew up and then we have two locations right now in Blair where we live. And it had originally been really that we would have this building that we would turn into a clinic had been sitting here for almost 18 years empty. And my husband has really built this from the ground up and I've decorated it.


It's been great. Third times a charm. So we did hit a lot better as far as working together on a project, but it was very drawn out because of COVID and contractors being sick and also getting hurt and then just time and back orders and shipment delays and. What ended up happening was we still have our clinic on the other side of town that we have been practicing out of, but we have kind of a split split party.


Now, we have some staff that really love that building. They know the flow, they feel comfortable and then we have some that love this new building. And so we are actually in the midst of trying to determine how we're going to start 2024 because we have all worked together in this 1400 square foot building.


And now we finally have this 3 story building done. And we're trying to determine if we're going to split staff and my P. A. Matt and I split buildings to work separately and keep both places open in the same town. And so we were talking a little bit about prepping and what are we going to do for the new year?


You know, that's one thing right now that we didn't foresee, right? That we didn't foresee that we would have this long drawn out process because of COVID. And now instead of moving over to one building and being together. We do actually have enough growth and Matt continues to grow his panel every day and our aesthetics practice and procedural practice grow every day that we could really have two buildings open in the same town of 6, 000 people.


So, for us, build outs and updates look a little different than what we thought and I guess that's the biggest thing I love to pass on to people is that. You don't really know what is coming for you. I mean, there was a patient that was sitting in our chair just this morning at our primary care office.

Cause I'm at the aesthetics in primary care now and her sweatshirt was basically, you know, just summarize like your future will find you, you know, you won't necessarily be looking for your future, it'll find you. So what you're meant to have will, will find you. So I feel like we spend so much time just organizing everything, laying it all out to try and even open our DPC door.


And we have to realize that it's going to be unique in its own way. And what we'll find, this will find us. And I almost remember having that conversation with you when, you know, you were trying to, to open and even find your place. Like it was so difficult and I understand that struggle, but it's so crazy because now the place you have, you know, it found you and that's your new home.

So what is your new home look like these days?


Well, yeah, so I laugh because there's, there's a lot there to it. You know, I, I love that that's your theme. You know, the theme represented on your patient sweatshirt. Before we jump to the update of big trees MD, I just wanted to ask if for those people who haven't heard about your clinic and how this new location within Blair is set up, can you just give us a quick rundown of like that you said three floors, but like, what are the spaces on each floor that you have that are going to be used for your practice?


Yeah, absolutely. And, you know, we'll show some pictures on this if it helps kind of bring light and shed light on how that looks. It's a, it's a downtown rural, okay, rural town, 6, 000 people. We're downtown on Main Street. However, the main drag does have four lanes. Because we have a lot of like truck and semi traffic that comes through for farming.


And so it's a busier downtown. It's not like Ashland where we have this quaint cute little brick road that goes through the main, main street. But they are building a bypass right now to take semis and whatnot around within the next year. And so it will be quieter, which will help aesthetically, um, and really even for patient parking and flow here in the downtown area.


But because that are, those, those are really all things that need to be taken into consideration as far as how I plan my business is that, you know, something that's important to me may not be important to the next physician, but for me, I tend to do a lot of the things in my practice that I know I would like as a patient because every day when I'm growing this business or career or even patient panel, um, Really a lot of the people that are coming, they obviously like the interaction they have with me or the relationship that they have with our staff or myself.


And a lot of times that really boils down to you have similar thinking styles, right? Or even similar things that you hold value to. And so for me, it's important to have not only access to your physician through a phone or your patient through a phone call, but easy to pull up to the building, easy to get out, easy to grab what you need quickly.


And so We found out very quickly that this three story building on Main Street doesn't have the easiest parking in and out like our primary care office over across town that's already open. You just pull up to a little parking lot and... Walk in the door and it's very small town. This one, since it is on main street, has more traffic.


It's harder to park. So, as of right now, our 2024 outlook, instead of moving us all over here into one building, we'll keep primary care over there and we'll use this location more as what we call a satellite clinic or a micro practice for our direct primary care. So we have on the first floor when you walk in, you can walk in off the main road, so downtown Main Street, or you can walk in through the alley door, and it's a clean, nice kept alley, so it's not like, you know, it looks trashy or scary, because we can have, we have two doors, we have one that you can enter and walk upstairs to more of like a loft.


Or downtown type setting that is our second floor called our mezzanine floor and then our third floor and they are when you walk to that second floor, they kind of flow together. So you can see both of them at the same time, but there is that 2nd and then 3rd, we'll do aesthetics and any procedures up there.


Anybody that can be mobile walk up and down there, you know, don't have any handicap accessibility issues. So they'll come up there for aesthetics and. Then as far as our first floor that you can enter either, like I said, through the alley door or through the front door, that will be where we'll have wellness area and market area as far as like buying any supplements or clothes or doing some of our wellness classes like yoga and stretching.


We have some contracts we'll have set up with physical therapy here in town for cash pay and they'll come in and see our patients like post op and do some physical therapy here. And then that little practice in the back, the micro practice that's separated from that, that front market, that's where I'll just have one room.


I'll do anything that, you know, somebody can't get up to the second or third floor for access reasons. Or if, like I said, I don't want to do primary care across town with Matt, I'll just, you know, run up and down the, from first to second floor to, you know, see a patient, maybe like a GYN procedure or something of that nature in the micro practice.


So I included everything in this building so we could always function out of it and work out of it. But in the end, instead of making it that first floor, a huge clinic for Matt and I, and maybe another partner at some point to work out of. We actually opted for making the majority of this building procedural, aesthetic, almost ancillary services, market, wellness.


And kept our other building the majority of primary care because it was just so easy to get in and out of there for lab draws, medication pickups, and even just busier practice like an urgent care slash primary care use. So that is what we did in the end. But again, at the beginning, it was all meant for us to be over here in this three story building and it was.


The delay of COVID that was a bear. And I probably could say I crabbed about way too much and my staff was always sad when I said it wasn't ready to turning into actually, I think what it was always meant to be, I just was trained to hurry the process along and couldn't quite see it all laid out in the end.


So. That is really how it'll be different and how we'll utilize both. We'll still do procedures, aesthetics, infusions, all of that over at our primary care site, so we don't make it difficult for our patients. But it will be more like, hey, you're here for an illness, you don't want to go to the ER, we'll save you ER fees, let's do some IV fluids for your Kidney stone here with some Toradol and not make you just jump over here to this other building to do an infusion here because that's where we want to do infusions only if that makes sense.


So, that is a little bit of it in a nutshell. I can ask. Or answer any specific questions, but that's the summary. Awesome. I think that we also should include the visual representation of me trying and attempting an IV on your arm when I was out there. Well, there might've been a couple of bruises, just a couple.


Oh my goodness. So check out the blog for that, but, oh man. So that's, I think it's great. You know, I think that what I'm pulling from that, you know, big picture is that like, not everything is just going to be perfect when you step into DPC. It's work, it's hard work. It doesn't always happen on the timeline you want.


And that's also normal. So I'm so glad that your space is where it is now, because it's, it's been so cool to, you know, when we're talking and FaceTiming and whatnot, to see the progress and. Because I remember when it was like This whole area of just like, there was like a pool table and like storage and all this stuff.


So it's very cool to hear. It's very cool. And you know, like when it comes to our practice, our space definitely has had to grow with two physicians because, uh, just, you know, as a quick update, um, my husband joined the practice and started seeing patients in September. Um, and yeah, and it's definitely something that to, you know, to speak to the power of direct primary care where it's like he's seen, you know, the practice open and, and go for over, well, it was almost two years by the time he joined and then, you know, the learning, the business things.


I mean, he's not necessarily. You know, like my middle name is entrepreneur, but at the same time, he's smart. Like all of us physicians who are choosing to do DPC and he's like, okay, got to learn all these things. So it's, it's definitely been, especially in this latter part of the year, exercises and learning.


And one of those things in terms of space is like learning, where did you move the thing to? Cause I'm like, well, I did have the measuring tape. So, you know, this is a. A nice story about DPC. I had a steroid injection that I had to give to a patient and the order for the steroid had come in already, but then nobody could find the steroid and it was like, Oh my gosh.


So I love that my patient was so gracious. She came in the morning and she was like. Okay, well, no problem. I'll just come back this afternoon, but just I want to make sure that when I come back that you have the videos of the boys like that was what she was focusing on and not, you know, like frustrated or anything because it wasn't, it wasn't like a big wait.


It was like, yeah, no problem. I'll just come back. Like, I felt mortified for like five minutes and I was like, we have to find the steroid now. But at the same time, it was like on her part, it was like, yeah, yeah. That's cool. Like I don't stress over getting in to see you. So that really, you know, as time has progressed, it's been one of those things where it's like, okay, I don't need to lose my cookies over this.


Like, how can we work through this? And if that's what you like are frustrated about, I didn't have pictures ready for you this morning and I'll show them to you this afternoon. Like, that's cool. So, but yeah, our, our space is with one clinic space and then we. This was off of, and I had mentioned it before when I had gotten, when I had opened the space, the doctor who had, who I had gotten our table from, she had shared this like Uber for moving services.


And so I employed them yet again. Um, I got some free cubicles in Sacramento. And they moved the, the service moved them up here. And so now we have a breakup of the, the lofted space upstairs. So I bought actually a, um, a mobile spray painting booth. Like that might sound a little funky, but I'm like. That's keeping it scrappy.


It was very interesting. It was this guy who he did spray painting, um, but he had to like bring his room with him. So he built out this room that you can break down and we've made it into a room. We haven't used it yet for patients because we're still trying to figure out how to maximize the use of it.


But. With the cubicles and that space, we have more structured space upstairs. And then we also have, um, our whole cardiac testing area for our MAT test or our VO2 max testing or CPETs. We have that separated now, which I'm super glad for because, you know, like before when I was doing our initial testing, it was like all dudes and they're like doing the EKG thing with no shirt.


And it was like, cool. But I'm like, what am I going to do for my patients who are not comfortable? Taking the shirt off. Right. So, um, I feel that our space is much more fitting of our needs, but that definitely happened over time. It's like Facebook marketplace and I are very good friends. It's probably not a good thing to be on it as much as I am, but I'm always looking for like, oh, like I can actually, oh, it is free.


Like, I mean, that's how I got my tables. That's how I, my table, that's how I got. These cubicles, so it's like, you know, it is a thing that you can go on Facebook marketplace and find good stuff. But yeah, we're, yeah, we were, we were talking, I think, a little bit about we were looking into a space and that it's still this long process of like, is this the building for us?


We're still in that process. So it's a no big update there in regards to the new space. We're still in our former space or our current space. I should say. Yes.


And, and how do you feel like going forward, you know, you have a very unique situation working with your husband, but you've done it before, right?


So that's the exciting part is that you've already shared a position or worked alongside him, but now it's so different because you have been, although he's been listening to you talk about this for years. Now he's physically going to be employing all of these actions and thoughts on his own, you know, and trying to learn that.


And I really enjoyed, like, I know he came to that, um, last conference and you were just kind of like, you know what, find your way, learn, hear, hear from someone else. And, you know, you had mentioned, I know it sounds mean, but I'm like, no, it is the best idea I've ever heard because you do want them to be well rounded and hear things from other people.


Cause that's what you had a chance to do as well. Yeah. And so I just applaud you for that because I think that was, um, very selfless and important and growth for both of you as a practice and a couple. And so. That's, that's very exciting.


I am glad that he went to Minneapolis because he saw what I've been talking about and I'm glad that, you know, with the next DPC summit planned, I'm glad that we're planning on going at this point.


So that's. I agree with you that, you know, it is totally necessary for people to talk to more than one person to hear all these different perspectives, because you might have one person talking about marketing and the way they're talking about it completely makes sense to you, but their way of bookkeeping doesn't, and then you hear, oh, this person's way of bookkeeping totally makes sense to me, so I'm emulating in my practice, Oh, apart from what I heard over here and apart from what I overhear, what I heard over here and learned over here.


So I think that it's definitely, you know, for anybody who's, who's going down this journey of DPC as a business model, it's some, it's, that's, I think one of the, the fun parts of DPC, how you can really craft it to your own, you know, right way of doing business. So as we talk about, you know, how we are all crafting our DPCs as independent physicians and, you know, some, some are grouped together, like previously, Dr. Clint Flanagan was on the health, was on the podcast talking about nexterra healthcare, but for the most part, you know, we have independent physicians who are micro practitioners or there's, you know, a group of three or five or whatever, we're And we've talked about this year, you know, how employers are continuing to come into the fold, how lots and lots of people are wanting to play in the space of DPC.


And earlier on the podcast, if you haven't listened to it yet, I definitely recommend listening to it. Jay Keese, who is the lobbyist for the DPC coalition, had shared about the three different bills that are on Capitol Hill. And those are pertaining to veterans, like I was mentioning earlier, being able to access DPC.


One is about having Medicaid recipients and beneficiaries be able to access DPC. And also one is to be able to use their HSAs for DPC. And especially on that, on that last bill that I pointed out. It's so interesting because I want to spend some time talking with you, Amber, because you are definitely, you know, you're more seasoned than me, you're living in a different geographical location, DPC, you know, it's, it's in every state, communities of all sorts and types love DPC, but when we look at the nation, you know, there's people like DPC.


Amazon bought out one medical, one medical had already bought a peak bed. There's all of these players now, including what I just mentioned, the brokers, the employers, all these people wanting to play in the DPC space. And I want to ask you your thoughts on like, where do we see ourselves as independent physicians being able to maintain the autonomy that we are building with DPC as the world around us continues to change?


Yeah, I think it's a very important question to stop and ask ourselves because, you know, with anything, it doesn't matter if it's lifestyle changes, if it's counseling and mental health, if it is. Trying to figure out a new way to balance your finances or juggle things. Like you always come up with a plan and you start to enforce it.


You know, it's like, okay, it takes about four weeks to create a routine that sticks, et cetera, et cetera. And, and it might go on that way for a while. Cause you're really passionate about it and you don't want to let it get down and you can, you don't want to go back to where you were and you don't want to, you know, stop what you've built.


You see all the positives coming from it, and then all of a sudden life happens, and you get really busy, and it also becomes a little bit more monotonous, because it's been there for a while, and it takes commitment, and then all of a sudden you wake up, and you're like, Shoot, I just started eating 15 snicker bars again, and, and 5 Diet Cokes, and I'm...


Not walking and I stopped taking lunch and, and, and I'm not saying I eat 15 Snickers. I'm just saying that like, it, it just, you can do like these huge things and make big changes. But unless we're cognizant of it, we can absolutely fall back into old habits and just kind of let gravity pull us in that direction.


And I feel that that is kind of what I'm worried about in the DPC world is that. Things are moving very quickly and there's a lot of great ideas coming out and we're employing them. We're making them happen. We're, physicians are very much go getters. They're motivated. They're committed. But sometimes we're also overwhelmed.


We're stressed and we sometimes need to also take that slide and, and take the easy route home as well. Just because sometimes we don't know what to do and we just have to make a decision. And I get a little nervous because, you know, we're doing all these right things and we're building and creating this direct primary care dream.


And dream meaning it looks different to every single person. It doesn't have to look the same. But at the end of the day, the mission is still the same for all of us. We're all doing it to try and make whatever little ecosystem we live in. You know, like everything I do really the way I do cash pay medicine and the way I offer direct primary care.


It really is built around what I think my people, my grandma would always call your people, your people, I feel like my people or my people of Blair, my people of Ashland or my people that surround me, what I feel like our community needs and what I think would help all of us bloom into healthy humans and go on to continue to pass this torch and make more healthy humans.


I feel like my practice is built around that, but it, at the core, it is cash pay direct care, right? Even though pricing might be different than, say, you in California, or my building might look different, or whatever it may be. Like, I'm offering somebody primary care for an affordable rate. I have memberships.


I do things a little different and have some one time off visits, and you pay for them only because that is what I feel like my community needs, because I have a lot of people that... They don't want a membership, they don't want commitment, but if I don't offer a one time fee and for a visit, then these people really just may not get care.


And so sometimes I have to give and take. It may not be the exact DPC model, but if it means somebody gets care that wouldn't get care. Then that's what's important to me and that's my mission and value. So I know that DPC looks a little bit different, but yes, at the end of the day, our mission's the same.


But I think in the last few years, there has been so much change so quickly and not everybody understands their mission and their label, or maybe they have different intentions and they're trying DPC model that I think that we're seeing some things like You know, people selling practices to these big guys that, you know, might then be turning it back in again to more of like this traditional insurance type model or people wanting to get out of the system quicker.


And so, instead of jumping into, like, wanting to create their own DPC, it takes a lot of effort, you know, they might be jumping on board with bigger systems and now just being employed and working for someone again. Or even like I use a health share and, you know, them trying to figure out and work out how do we use these health share cards and how do we have people submit bills or try and make an appointment and then it ends up that now they've negotiated contracts with, you know, hospitals that don't look too, too much different than like an insurance contract, you know, I just think that it's moving so quickly and university.


If we don't stop and realize why we're doing what we're doing, that we're going to get overwhelmed really quick, especially in COVID and everything it's led to. And we're going to end up in the exact same path that we were going down before, and that's how DPC came about. And I get worried because COVID did burn a lot of people out, and I tell my patients right now, Like there's a lot of people that I feel like are waiting longer than I wanted them to, and never would have waited like that a couple of years ago, because there's some weeks where I catch our practice going back into prior off and paperwork and somebody sending something.


And I have to stop myself and say, no, no, I will not fill that out because this is not my practice. This is not how I built it. This is not, I'm not writing this order for you. You don't like this is. And it's not doing anything that's detrimental to the patient, it's more stopping and saying this is a HR and, uh, like clinic policy flow issue that we weren't supposed to have because we weren't going to do it this way, but because COVID caught everybody off guard and like I got so overwhelmed even and I started just doing things to get them done like I used to, you know, at my prior practice where you just have to stay alive that I had to stop myself and be like, stop signing things, stop doing this.


You're letting someone now mold your practice, and you were supposed to mold your practice. And so, I guess, I hear you saying that, and I worry about that too, but not just from a physician working for someone, but I worry about it for like, health shares working with hospitals and clinics, and I worry about it with yeah, entities that are jumping in from an insurance standpoint.


I think that we're gonna have to just stop and take a breath. All of us for one second and say, okay, what is our mission? And are we following it at the end of the day? Or we're all going to be in insurance contracts again, employed or owned. That's what I hear you saying that you're worried about. And I feel that same way.


And I love that, you know, you're. Brought up, like focusing on the mission because, you know, in California, there's a group of us who are, you know, meeting regularly and we're voicing those opinions and they're all opinions from all, you know, sorts of trauma, backgrounds, insights, all of these things. And there's, you know, there's, there's groups of people like the Houston, uh, doctors are, they have a community, the state of Georgia had like one gathering where people were getting together.


But in the reason I mentioned that is because. I love when, and that's, you know, one of the, the key missions of this podcast is to talk about DPC because there is no one right way to do DPC, because if you've seen one DPC, you've seen one DPC, but at the same time, I think it's important to, you know, To speak up and to say your opinion, whatever it is respectfully, because, you know, we've had too much, too much in this country about like, oh, you said one thing.


So, like, curse on all of your generations to follow, you know, not that type of, you know, we don't, we don't need that in this movement. We don't need division and divisiveness like that. But what we do need is people to be at the table. And I think that's where. Whether you're talking to someone, you know, in your community, who is the program director, or if you're talking to someone who is in your state house of represent or state legislature, or whether you're talking to someone who is an employer of many, you know, hundred employees or hundreds of employees or whatever.


I think that putting your ear to, to the ground and listening to the conversation, but also saying what your truth is as an independent DPC doctor matters, there's a tendency, you know, like I, I switched out of. Like pre med, whatever major I was in at UC Davis, and I switched into anthropology because I was like, you, you NPB people are like super cutthroat and I can't handle this.


I just need to like learn how to dig in dirt and like do anthropological stuff because I need, I need a break from my OCHEM, you know, classes and whatnot. But I think there's a tendency. That I saw it and I, I think I saw a tendency in undergrad and then in medical school to like, to always shine and be the best, especially if you were in a very cutthroat residency or historically cutthroat residency or specialties.


And while I think about, you know, DPC as a movement and speaking up individually and sharing our stories as independent doctors, I do think about our tendencies as. Medical students, medical residents, you know, like the culture of, like, I want to stand out. I want to be the best. Some people use the terminology cutthroat.


But I think that, you know, while we're growing DPC and there might be a DPC, you know, popping up across the street from you, Nitin Gupta put it great. You know, it's like, yeah, there's like, For gas stations, all one on each corner of the intersection and like, that means that's where you go to for gas. It's not like, oh, you know, everyone's going to go to the, you know, the Dynaco station.


Like, that's not what it's all about. And by right, and I think I'm going to stop you right there because you mentioned like. Does this make sense what you're trying to really bring forward and, and really employ so people understand why you're passionate about this. And I think that is the perfect example is that four gas stations, right?


You have four corners, four gas stations, people would be worried, right? That's good. Somebody is going to shut down. And you know what? In the end, somebody might shut down because there is a chance out of those four gas stations or say four clinics that somebody works harder or somebody has a better.


Personality or somebody does a better clinical practice or, you know, they have more staff or, you know, whatever it is, you know, there's always going to be something that closes and something that thrives that there will, right? And that's why you always have to evaluate, like, how many clinics per se, or gas stations you have in a certain area or scooters, coffee shops or whatever it is.


But at the end of the day, too, can 3 or 4 places or et cetera, 1 or 2 work in the same vicinity and work together? I truly believe, yes, if, if you go back to the beginning of what you said is that we're following our mission, and the reason it works is because if we're all following our mission. Then we can have our own little piece in all of this, which is why I think there is a place for hospitals.


I think there is a place for insurance. I think there is a place for employers and employees and even employed physicians, et cetera, but it's never in that mission to say, hey. Let's make this like insurance, right, because we're all trying to make it easier for someone to access care for doctors to work and enjoy their job and take care of their patient without making it difficult.


And I feel that that can be done. Like you're saying, you can go out and you can teach these residents and these training and educational universities across the United States like. How do we teach people about direct primary care? What makes it different? How do we not fall into old habits? Someone does need to teach them that just like here in town, you know, I might have been employed at the hospital before, which I was, but I still help them with C section call and they have their own little way of doing some cash pay model.


But we still work together on still bringing services together and doing what's right for the patient. Because at the end of the day, we want people to stay in Blair and get care. We don't want them to drive 30 minutes up the four lane to Omaha. So how do we work together to do that, right? And we both are going after that same mission, is that we want people to get care.


Theirs looks a lot different at the end of the day. They do a lot of insurance. I don't, right? But it doesn't mean they don't want to work with me, because we have the same mission. And I just feel like there are ways to include everybody in this. But from a direct primary care and physician, like if we're talking about physicians, We need to make sure we all know what that mission is and may that be employed or non employed.


I thought the mission was always going to be that we're putting that patient and our own personal health and wellness first and what we love. So we can make this direct primary care model. And I feel like that's changing quickly because direct primary care is new, right? Anything that's new, it's... It's kind of passed around.


There's a lot of, you know, changes to it. They try and ebb and flow, but I just hope we don't lose that unique direct care mission that we do have that we really built our foundation and roots on because we're trying to make things change quickly or be all inclusive or make it what it's not or sell it off for a price or, you know what I'm saying?


I, I think that's What I hear you saying and what you're worried about, uh, making sure everybody can work together, but not changing it drastically. Right?


Absolutely. And you know, the, it's interesting because like literally earlier today, I got off a call with a person who's doing research in perinatal access to primary care and services, whether it be rural or urban.


And, and they had attended the FMX for AFP and sat in the talk about. Direct primary care. I don't know which one because I think there were two, but this person was like, so where does insurance come into play? Because if a person has insurance, like, how do they use it? And I'm like, I love that you're asking this question because clearly the takeaway wasn't necessarily made that clear for that particular point in, in whatever lecture you attended.


And I think that's really important for people to understand that it's like, you know, you, everyone should have, in my opinion. And I think this goes along with the mission of like. Access to quality care also, you know, speaks to us being able to help our patients make smart financial decisions and not put people into financial bankruptcy because, you know, we don't even know what the cost of care is like we don't actually know that when we submit a bill or submit codes for, you know, whatever it is, that if it's covered or not covered, and then what is the patients out of pocket cost after their insurance kicks in, you know, it's, I think that, you know, Making sure that people, you know, know, no, I'm just laughing because, well, for one, we do always say there's direct primary care, cash pay, et cetera, but also knowing your value, right?


As a physician, no matter who you are and what specialty you have and primary care services and things you offer, right? Knowing value, but I laugh because. I do know my value. I do know like where things should be, but I also know how I practice medicine and I offer things at my clinic and I'm a very fair person.


So, you know, I'm not going to let. One person or three people run around and get some special deal and then have somebody else in a town of 6000 that, you know, they don't because I'm playing favorites. Like, I just don't do that. I'm, I'm very fair and I'm, I am, I'm honest to a fault. And so I'm laughing because as you're talking, I'm thinking.


Of conversations from the minute I started my practice and it's still happening now, almost six years later, my husband is entrepreneur himself and he always tells me, and he's a very fair and like level headed as far as value. And he's just a great guy all around, but the thing I laugh about is he always tells me you are the only business person I know that talks himself out of money every day.


And I laughed because he's right. You know, I just had a discussion with a patient today, like you could do this, but if you did this and this and this, you know, it'd be more affordable. And then we could move this around. Like, I'm always trying to figure out a way to make it more affordable for the patient.


So then they absolutely follow through with making a good choice for their health, but yet I'm still offering value. I'm still paying myself and keeping my staff and I'm also being fair. So I'm not. You know, playing favorites or doing something that's not appropriate. I feel like, um, from one person to another, but I do laugh because sometimes when I think of direct primary care, I think of my husband saying that.


You know, you do know you're the only business person that's wants himself out of money every day. It just kind of makes me giggle. So that's what I was laughing about. So sorry to throw you off.


I can totally hear Jeremy saying that. So that's, oh my gosh, it's so funny. But you know, I, I just, I go back to when I was talking to this researcher earlier today and I'm like, at the end of the day, What DPC brings to the table is, and all the things, you know, affordability is one, yes, but patient accessibility to a doctor who knows them when they need that doctor, how can you not be in love with that, right?


Like, yeah, patients, doctors, and having the time to be that doctor who is in that relationship with your patient, it's, there's nothing like it. And then, you know. That's how I summarized, like, why, why do people pay for a DPC membership? It's like, well, there you go. And she was like, and this person, this researcher was like, like, that's, it's so simple and it is, I mean, it literally.


Is that clean and simple? But again, I go back to, you know, as there's laws on Capitol Hill as you know, state organizations are recognizing DPC or not recognizing it as state laws protect DPC or if they're not protecting DPC, whatever your whatever your geographical area is, is doing with DPC or acknowledging or to the extent it's acknowledging DPC, I definitely encourage people to speak up to, to whoever you can so that, you know, you don't know if they will make a difference, but we know that word of mouth works for growth of our practices.


It definitely also works for, you know, the, the experiences that we have as physicians who have chosen to practice in this model. So thanks for everything 2023. Welcome 2024 Spirit. Tell me what's, what are your big goals for 2024?


Big goals. Hey, you know what? How about after four years of working on this building, we open and we stay open.


That would be a huge goal of mine and, and definitely how to balance three different locations currently still being the sole physician and then also running admin of all three, um, after we had. Unfortunately, our trained lead after about six months, she had to go. She had her own family business that they had to take care of and put first.


And I totally get that. So I have continued to manage that. So my focus. With that being my role right now is, you know, being admin as well as physician is really trying to learn in 2024 how I'm going to balance all of that from a family and clinical as well as administrative practice. Because I have a way, and I know you're just going to think this is comical, Mariel, like there's no way this could be me, but I have a way of jumping from one thing to another, quite often, say ADD if you will, or squirrel, we, we do like to call us squirrels around here, but I know, as far as even organization, that is it.


Not only makes my brain have a difficult time closing something out, but I don't get as much done as I think I do. And so my focus for 2024 is really having more of a set schedule, which not only will probably make my life easier, but everyone around me, it would make life easier for them as well, because they're always trying to figure out when's Dr. Beck and I are going to put a patient on the schedule or when's she going to do the ordering for pharmacy? Um, but just really try and organize that out. So when I have a day come up. That it's blocked out for admin like I have the boundaries to say I will not add a patient, you know at this time I really find it's important to do that because I think I Put myself in a bind sometimes because I do know I have a day that I could take care of a patient or just do a quick phone call But then it adds on two, then three, then four, and then pretty soon I'm a half day into a patient day that was supposed to be admin, or maybe a day I'm supposed to be with my kids, and I lose track of that.


So it's really important for me to have those boundaries in 2024 and take care of not only like my family, but also my clinical family. And make these three places come alive and see what they can do. So it also includes financial planning because we're at a spot in our business right now. That my crew that's been with me are just like pillars, man.


They are soulmates. They are great people. They have stuck through this last couple of years of building breakdown and rebuild. And that took a lot. Every time, even when we would all get frustrated with each other. Like there was times they, some of them wanted to walk away and they not only have faith in, in me, but they have faith in the healthy human and what we can offer the town and they want to be a part of that.


So I want to be able to give back to them. And so we're making some financial changes with our business. As far as what we offer for benefits and even just doing some restructuring for our like retirement planning and, and how Jeremy and I foresee, you know, the world as we create the healthy human for our children and our legacies and, and, you know, selling practices down the road as we age.


So that sounds like a lot, but we have a really good person in our court for financial planning and I just look forward to. You know what? I'm not expecting it all to be perfect by the end of the year, but I'm hoping this is a real building year for organization and financial planning that then in 2025, you know, we just see it all come alive.


So it's a lot to ask for, but I mean, I think we're ready for it. We've been waiting for this moment, so I'm really excited for it. How about you? Yeah, well, you know, like my little spidey ears were like, or spidey senses, whatever I like up every time you said organization, I'm like, there are some things that I Love to do for organization. Like I love to organize other people's things when it comes to my own stuff. It's always like, Oh yeah. Like, you know, atomic habits. Remember if you did 15 minutes a day, like that's seven and a half hours a week or whatever it is. So like, it's very easy. Like how you're saying, you know, like, Oh, I was great.


I was doing all the things. And then I'm like, how am I eating a Snickers bar? And all the chocolate from my kids, Halloween candy is all gone because it's in my stomach. Um, you know, so organization is definitely something that. is a, is a huge focus because now I have myself, I have our VA and I also have my husband.


And so what I'm realizing more and more now is how to be efficient as a team. And that, for me, looks like having Better documentation of processes so that, you know, when there's something that needs to be done, like there is a, oh, yeah, I can look for it. I can easily find it and I can easily follow something, whatever that is like, you know, what happens when something arrives at your door.


Like curettes, like what, how do we inventory this? It's like, oh, okay. So you haven't done it because you're new to doing this, this portion. So like that, if like, if a medical student comes on or another doctor, it's like, that is, we're finding little places where we have opportunities to change it so that we're tighter as a clinic going forward.


And we're not like, oh my gosh, I don't know what to do. And so organization is a, is a big thing. Yeah. I think also. Being clear with communication is, has also been a big thing. So we've had this discussion lately about if you have a task, if it's not explained in detail or whatnot, that might not be enough for somebody to follow that task or complete that task or whatever.


And so I think that that's, you know, it's not just DPC, but that's a lesson that we are learning when it comes to the business itself. Like, you know, we've been a family for more years and have had. a DPC. So it's definitely in the, in the entrepreneurial range rather than the husband and wife, mom and dad range.


But when it comes to the, the add on of patients, like I wanted to talk about that because I do love boundaries. Like that was the whole talk of our panel that I moderated earlier this year at the summit in Minneapolis. Yeah. But what I will say also is that The, I do love the ability to say like, I will have boundaries and make a little exception.


So for example, I do not want to see patients on certain days of the week if in person, if, if I can, you know, make that happen. But I did love when, you know, I, my, my mom, my pregnant mom was like, I, I'm worried about blah, blah, blah. And I'm like, fantastic. I'm so sorry you're having that issue. But the fantastic part is that I will see you in 30 minutes in the clinic.


And they were like, what? And I was like, Yeah, this is why we don't have thousands of patients so that you can have access to care when you actually need it. And so, you know, I did love that ability to be there for my patient when they needed me. So I will just throw that out because you can, you can even.


You know, narrow it down to, I will not see patients unless they are pregnant or unless they are bleeding and they need stitches, you know, so even those types of boundaries still allow you to respect boundaries, but also allow you that little like, and this is the icing on the cake, you know, so yeah, but I think that that's the biggest thing for me is organization and communication, um, follow second.


Yeah, I just have to, again, giggle just a little bit because that is the true doctor in you and in me that drives nurses absolutely bonkers that we always have a but. I won't put a patient here except or, but, if they have this, this, which is why they're always like, I have no idea what she's gonna do and it drives me nuts.


But you know what? That's part of why we do well as entrepreneurs is that we're able to pivot quickly and it's also as much as it drives people crazy, it is part of why they like us as people, as humans. So, you know, they're just, I think they're going to have to roll with some part of that pivoting because.


As a physician, that's really what we have to do when we get patients calling us at all hours. We're, we're triaging sometimes as much as the nurses are triaging, deciding is this urgent? Is this not, you know, do we bring them in? Do we send it in? You know, and so we can't ever predict that any more than anybody else can love it.


So for the healthy human, do you guys have, you know, have you been using, or do you have any pro tips for the listeners in terms of like big things that you make sure happen before

the end of the year? So again, as much as I try and organize myself and be. I don't even want to say the word boring, but in my eyes boring because I don't, I don't love committing to a plan that's the same every day.


And so family medicine of you. Yeah, so it is. Yeah, it is. That is actually thank you for saying that because it's not necessarily that I'm trying to be a jerk and it's not that I necessarily have ADD. It's just so very. Family medicine of me because we like every part of medicine, right? We're a jack of all trades, but the reason I say I don't necessarily have a set lineup is because I like to do things different every year just so I can offer different things.


I don't, you know, kind of like you and I, um, are going to get together for this fun pop up event that you and I are planning that's secret. You know, it. It's just one of those things where I like to surprise people, I like to keep them guessing because we always do fun stuff and that's part of also why our patients like to be with us and our staff does and but every year at the end of the year, I do as yes, I'm looking at what can we do different for next year and I kind of have a theme, you know, usually of what my goal is and what I'm trying to broadly decipher and or maybe try and improve for my my clinic staff because they've You know, told me enough feedback that I'm like, okay, I'm hearing this repetitively over and over because we do our annual retreat every year in September and we have usually done, um, employee reviews on like the annual reviews of when they've been there with us for a year, we do them at six months in a year.


But this year we have decided, or I decided every year we will do annual reviews right after the retreat. So we'll have some good fun and then we'll do your review. And then we're kind of close to the end of the year. So we can start employing that for the next year. And so we did all of our annual reviews.


We kind of talked about some things, you know, they, they review me, I review them and we kind of decide what could make our clinic better, whatever may be. But we do that as a staff and a clinic. So processes you're talking about are ways to make your clinic better staffing or culture better. But then from like a patient thing we like to do at the end of the year is that I just really love holidays.


My mom made birthdays and holidays really important. We didn't grow up with a lot of money, but. be darn tootin that every birthday you would wake up and the house would be decorated in one spot for you and your presence would be on the table. And, and I do that for my, my sons and my husband, even every year, you know, so it doesn't have to be a lot, but it definitely needs to make sure people feel loved and welcome.


And I really appreciate all the people that. Chose to not only jump, you know, the traditional ship and come to DPC with me because I'd only been in town, you know, for like seven years when I made that jump and I'm not from here and they were very loyal to me and then I have a very large amount of my patient panel that are new patients to me that just took that jump to come on board and learn DPC and, you know, maybe heard that I was a good doctor and they wanted to come check this out or maybe Matt was a great PA and they wanted to come check him out.


Thank you. So, we like to do November and December kind of like little specials and pop ups. We do offer a lot of procedures at our clinic. We offer other ancillary services, like I said, IV infusions and aesthetics and things. So, like right now, this week was Veterans Day week and we did a block on Thursday for any veterans to come in and get free PRP and PRF.


If they scheduled with us on that day, they had free PRP platelet rich plasma and PRF treatments. So that was one thing we offered. And then we also had this week what's just called Thanks for Thanksgiving. And we did a special where we did, you know, a discount on our Botox and we did a discount on Our procedures, um, because we do charge a procedure fee of a hundred dollars for every procedure.


So we did like a 50 off and skin checks with that. And then we'll offer more, you know, specials on some of like even our market items and other services we do throughout the month of November, just to thank people for utilizing our practice and picking us and if there's any way we can, you know, make that better.


We try and make our practice better and, and, you know, just the, they utilize services. Maybe they didn't even know we offered. And then we use that like a little downtime for our staff to have a little bit slower day and connect too. So we ordered Chinese yesterday and we ran the schedule a little differently so we could connect just each one of us together and, and just have time to talk.


So. You know, we run a pretty busy direct primary care practice. It's not slower. It's not like three to four people a day. I mean, we are seeing quite a few people in and out between nurse visits and then myself and Matt. So it's a pretty busy practice. So days like that are really fun for our staff and

It's good for our patients. And then usually around Christmas, you know, we'll try and do something like we might do membership giveaways or give some money off a membership of somebody that is having a hard time in our practice. Or we are going to do something different this year. Cause we're opening our new building.


We have a fireplace since my husband's a fire pit and fireplace guy, you know, he put that in and we have a patient that wants to be Santa. So we're going to have Santa. And then we have a patient that is, uh, an amazing guitarist and singer, and he's going to just sing and play the guitar and, and we're going to let people come and get some drinks and mingle and check out the building and do a Santa and sing.


You know, so we just like, I, I'm kind of an experienced person. I, I enjoy a good experience. I'd pay for a good experience. You know, I think life is what you make it. And I really don't have time to be boring. I really think life is about being fun. And I think I drive my husband crazy with that because he would live on a mountain.


With like a pot of coffee and one sweatshirt and life would be absolutely ideal and not talking to anyone for weeks on end. Like that would be his ideal situation. I'm not that person. So I think it's just more, what can we bring to the practice? What can we tie that year? You know, up with and, and really forge forward for the next year.


So, I mean, I guess that's not very clear because it's never the set thing year to year, but it's what's fun. And it's really, I really, this year, I think when I got sick and I have surgery this summer and, and I have had a harder year, like I said, with illnesses and it also delayed some of opening this building is that I just really focused on.


Not necessarily. Oh, like, Oh, I only have so much time in life. What am I going to do with it? I mean, I'm not really that person. But what I did want to do is, is stop and say, Whoa, whoa, whoa. I've been open like almost 6 years and there's some of these years and I've learned this from staff's feedback. And also for me, sometimes going back and looking at photos or.


Even planners of just like, there's been some times in here where I lost sight of what I was really doing with this practice, like what I wanted to do long term and I've definitely started creating someone else's dream, not mine. And that happens as you grow a staff and you get other people's, you know, advice and input.


And I just really tried to reel it in in the last four to six weeks of saying, like, in this year with what is important to you, what's special to you, what makes healthy human, what it is, go forward with that same mindset, because at the end of the day, like, no matter what I want. To be able to look back and be like, Oh, I did that because that is really how I like to do things.


And that's how I like to care for patients. I don't want to look back and be like, well, I don't know why I did that. Somebody talked me into it, I guess. I mean, I would have never chose to do that. You know, I don't want to look back and say that. And I think it goes back to what you were saying about the politics of it and having middlemen involved and having other people involved.

Is it, it's very easy to just start gearing your practice towards what that looks like. And you have to stop yourself and say, no, no, no. I left the system and I even still leave my kids every day.


Sometimes more than I want to, when I, you know, thought I would be this entrepreneur, but if, if I'm accomplishing what I said, I was going to, going to accomplish, then I've nailed it.


And I guess that's what I try and do at the end of every year.


That's awesome. I would say that ours is probably not as deep. Uh, and we, we

were down to the point where we have, yeah, but you're new, right? You haven't really let somebody sway your thinking yet because you're still building what and creating what you want it to look like.


Right. This is true.


But I, I laugh because like, you know, even just doing a staff retreat, I'm like, You know, a third of the practice I see literally more than any person on the, on the planet. And then the other person, all of our patients think that Dom is sitting in our office and they're like, Where, where's Tom?


I thought I was going to meet Tom today. And I'm like, someday she will come and she will be here, but that's not today. And so I laugh because it's like, that's awesome. I love that you guys, you know, do your retreats. And I think that's so healthy for culture. I think that, you know, that's one of the questions I love asking for previous guests, especially like, you know, how do you maintain the culture of your practice so that it continues to represent the mission of the practice and the goals of the practice.


And, you know, for us, I think that. Like a lot of reflection away from like SOPs and you know, all of those things, but just reflection and ways to improve the practice, um, from the patient experience. So we're, uh, Allison Edwards had mentioned a particular survey and we've incorporated that survey, but we're going to send that out to our patients, um, to see like where, you know, how you, you talked about, like, you guys review each other.


We want our patients to, you know. Help us help them. And so I think that's a big focus of, are we, you know, it's a big check in as to like, are we meeting our mission? If like, if, you know, we're not doing, you know, the best that we can in one arena, it's like fantastic. We, we will learn from it and then we will move forward.


But I think what helps is that. In DPC, you even get, I mean, you, you can make changes. Like I I've said this before and other people have said this before, but it's like, instead of being frustrated with like, I can't get this workflow to work or whatever, it's like, no, you literally can just be like, okay, patience, let me know.


And then great. We can take that input and actually make changes. And so, um, I think that that's, that is like, I think where we're really focusing on the end of the year. But I think that's, that's our big focus for the end of this year. And I definitely would say, you know, whatever the listeners might be planning for their end of year.


One of the things I definitely challenge everyone to think about is just like, how, like ask, ask yourself, like, how did this last year go for your practice? And is there in particular anything that you can recall that like, did you did awesome at something that was an opportunity to grow from? And just, you know, taking a bird's eye view at like, holy smokes, look where I was and look where I am now.


Yep.


And, you know, you said your practice, but what's interesting about that is you can apply that to anything, right? One of the biggest things is. You say, Oh, that's deep. And I don't know that we're there yet, but it's funny because I guess as a good friend of yours and I get to speak with you as much as we can, sometimes we don't realize what we're saying, right?


Because I'm listening to you. You're, you're the one you're speaking, but you did the exact same thing. You do that every year with your podcast, which really was your. Clinic baby before a clinic, right? So you, you have created this podcast and geared it towards what you want. And sometimes you reel it back in and you're like, okay, am I meeting those goals?


Am I creating this? And so your vision is a little bit different only because you did a little different than us. Like you, you interviewed all of us and then created this podcast baby in this home. For physicians to go to and then inspire them to go out and help patients. And it's a little bit opposite in a way, but all in the same mission.


And you are now building this clinic and making it what you want, but you do that every year, you know, with your podcast and recentering and making sure did I meet. My personal values with this. And so I guess the biggest thing is, is people just can realize that, I mean, they can do that with anything DPC or anything in life, just making sure you're, you're meeting those, those missions and values.


So, I mean, I think you do a great job reevaluating that podcast every year and just, What am I trying to teach my listeners and what am I trying to bring for an experience because it's the education of the physician instead of not necessarily always education of the patient, so It's a great spot for all of us to come.


So we appreciate that, Mariel.


Well, thank you so much, my Calabasca sister. And I wish you and all of our listeners, the best happy holidays and see you in 2024.


Oh gosh, that's so crazy. But yes, 2024, Nebraska with snow and California with sun. And

random, random last minute, like celebration. The last day of the year is one, two, three.

One, two, three, one, two, three. Oh, that's creepy.


Oh, man. Only you would have looked that up already. You're such a geek. Well,

I will see you later, sister.


Okay. You have a good night.


Hey there, MyDPCStory listeners, it's been a great season three, and I am so looking forward to season four. As we wrap up the main stories of season three, I want to put a call to action here. If you've benefited from the stories highlighted on the podcast, consider donating to the pod's efforts. The donation link is in the show notes and on our website.


While waiting for season four, check out our website at MyDPCStory. com, where you can find more episodes and previous sketches. Yes. And while you're there, pick up some DPC swag and find helpful resources for anyone, no matter where they are in their DPC journey. If you're not subscribed yet, follow the show today, whether it be on your favorite podcast platform or YouTube, as we'll be bringing some special episodes before we start season four.


Be sure to keep sharing the episodes with physicians who need to know about DPC. And for more on DPC, check out dpcnews. com. This is Mariel Concepcion. Happy holidays and thanks for listening.



*Transcript generated by AI so please forgive errors.

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