Direct Primary Care Doctor
Dr. Marguerite Duane is a board-certified family physician who decided she would be a doctor when she was just 8 years old as she witnessed the birth of her baby sister at home! That transformative experience fueled her passion for family medicine and desire to one day do house-calls! Today, she is a physician with Modern Mobile Medicine, a direct primary care house-calls based practice serving patients in the DC metropolitan area.
Previously, Dr. Duane served as the medical director of the Spanish Catholic Center of Catholic Charities, a non-profit community health center that provides care for an almost exclusively poor and uninsured population in the DC metropolitan area through a direct pay model. Prior to that, Dr. Duane directed the Family Medicine clerkship at Georgetown University, and she still holds an appointment there as an Adjunct Associate Professor. Additionally, Dr. Duane is co-founder and Executive Director of FACTS – the Fertility Appreciation Collaborative to Teach the Science, a non-profit group dedicated to educating students and healthcare colleagues about fertility awareness based methods and their applications for women’s health and family planning. She is trained as a Medical Consultant in Creighton, FEMM and NeoFertility.
Dr. Duane received her M.D. degree with recognition in primary care from the State University of New York at Stony Brook and completed her Family Medicine residency at Lancaster General Hospital in Lancaster, PA. She received a Bachelor of Science with Honors degree and a Master of Health Administration degree from Cornell University. She has previously served on the boards of both the American Academy of Family Physicians (AAFP) and the Family Medicine Education Consortium (FMEC). Dr. Duane balances her career as a teacher and Family Physician, with her role as a mother and wife. She is proud to be accompanied on this life’s journey by her husband and fellow family physician, Dr. Kenny Lin, and they are delighted to be the parents of 4 young children.
In today's episode, she shares how she built her dream practice panel up after realizing she did not have to practice as a family medicine doctor full time! For an amazing example of how DPC can prevent churn, she shares how she went to do a research fellowship in Utah during the pandemic. During her fellowship, she was only available for in-person visits when she would be able to fly home and over 90% of her patients chose to continue on with her care despite being primarily cared for through telemedicine. Hear her incredible story today!
Articles written by Dr. Duane:
Resources mentioned by Dr. Duane:
- St. Luke's Family Practice (The "Robinhood" DPC in Modesto, CA. FYI: the Doctors who run St. Luke's will be on the pod in a couple of weeks!
- Dr. Brain Forest - featured on a Medical Economics interview here.
CONTACT:
dr.duane@mmmed.care
TRANSCRIPT*:
Coming 07.25.21
[00:00:00] Dr. Maryal Concepcion: [00:00:00] Welcome to the
[00:00:00] Dr. Marguerite Duane: [00:00:00] podcast, Dr. Dwayne, thank you so much.
[00:00:03] I'm thrilled to be here.
[00:00:04] Dr. Maryal Concepcion: [00:00:04] I wanted to start with your decision to become a doctor at such a young age, because I find that that story with you seeing the delivery of your sister is definitely not something that a lot of people experience.
[00:00:17] So what was that like for you and what grew in you that drove you to become a physician?
[00:00:22]Dr. Marguerite Duane: [00:00:22] I remember that fall day in 1979, like it was yesterday, it was November 2nd, 1979. And I was just eight years old. And my mother had decided willingly and knowingly to have her last child at home, basically because she had a bad experience with her previous delivery when she had my brother a couple of years earlier.
[00:00:43] And she also wanted us to be able to experience that. And so I can close my eyes now and I can still picture where is. Was in the room, whether it was my older sister timing, the time of the delivery, or my two year old brother who was out on the porch, looking in through the window, wondering why all of these people were around [00:01:00] his mommy.
[00:01:00] And I sat at my mother's feet next to my older sister Therese. And we both were in awe as we watched our baby sister come into the world. And I literally can remember in that moment, thinking, this is what I want to do with the rest of my life. Like I want to care for women and children and be a part of this miracle that is life that is caring for other human beings.
[00:01:26] And so I still pinpoint my decision to become a doctor to that day when I was just eight years old. And I never wavered from that. For me, my calling to be a physician was very clear. The ironic thing is I never actually met a family physician until I was in college. It was only a few years later that I realized I really wanted to be a family physician, because as much as I was in awe about the experience of labor and delivery, I knew that I loved children and I didn't want to give up [00:02:00] caring for children.
[00:02:01] And I actually need through my own experience as a child that suffered from severe asthma, that it was the support and the help of my family. When I would have an exacerbation that made it either much better or much worse, if they were there and supportive, it would make it so much easier to manage versus if I was alone and scared and isolated.
[00:02:22] So very soon after within a few years, I knew that I wanted to do family medicine. And like I said, I never wavered from that decision. And to me it's incredibly beautiful that after. Having that experience nearly 40 years ago, my practice today is an entirely housecalls based practice, where I go into people's homes and provide care for women and children and fathers and brothers and grandparents, people of all ages from before birth until natural death.
[00:02:53]It's just such an incredible honor and privilege to have a calling from a young age and to be able to [00:03:00] live out my calling through a direct primary care practice model,
[00:03:03]Dr. Maryal Concepcion: [00:03:03] in your practice currently, do you do any home
[00:03:06] Dr. Marguerite Duane: [00:03:06] deliveries? I wish that I could. I really do as a family physician, we are trained to do full spectrum family medicine, including prenatal care and deliveries.
[00:03:17] And for the first five years that I lived and worked in Washington, DC, I did do deliveries at Providence hospital, but Five years into practice. I became the medical director of two community health centers, where I oversaw a staff of 50 and primarily switched to more administrative work. So I cut back significantly on my clinical time and stopped doing deliveries.
[00:03:40] However, I have a passion now for reproductive health and in particular restorative reproductive medicine and helping couples who are trying to achieve pregnancy naturally by getting at the root cause of their infertility. So I work a lot with patients and helping them achieve pregnancy and monitoring their pregnancies [00:04:00] and attending sometimes more so to be there when the baby is born rather than to be the delivering physician.
[00:04:06] So I have a couple of patients that are due this summer. I'm really excited about, and they've already asked me, will I be there at the delivery? So when the baby is there, I can take care of the baby as well.
[00:04:15]Dr. Maryal Concepcion: [00:04:15] Even though, you're not actually doing the home deliveries, you're there, when that baby comes into the world and when a healthy baby comes into the world, it is so beautiful.
[00:04:25] Dr. Marguerite Duane: [00:04:25] Absolutely. It really is an incredible experience and it's wonderful to be able to work with our healthcare colleagues, certainly certified nurse midwives who are trained to do home births. It's encouraging that I don't have to bear the responsibility, but it's also nice to be able to be there, to be present and be a of that just awesome experience.
[00:04:45]Dr. Maryal Concepcion: [00:04:45] when you mentioned that you transitioned away from as much clinical medicine as you were previously doing, prior to opening your direct primary care practice, what was your clinical experience like in your professional experience?
[00:04:59] Like [00:05:00] before you opened your
[00:05:00] Dr. Marguerite Duane: [00:05:00] DPC? Sure. So I did my residency training at Lancaster general hospital in Lancaster, Pennsylvania, and absolutely loved it. I felt so well-prepared to practice medicine in rural settings and urban settings. And I actually spent a year after residency doing locums, where I worked in Western, Alaska and San Antonio, Texas.
[00:05:21] And, A normal sized suburban town in Pennsylvania. I did student health and I worked at a nursing home. So I got a lot of experience in a lot of different areas of the country. And then after I married my husband, who's also a family physician, Dr. Kenny Lin he's one of the associate deputy editors for the American family physician.
[00:05:41] He was accepted to do a medical editing fellowship at Georgetown. And we moved to Washington DC. And there, I initially started work at a community health center at where like most community health centers, you're expected to see eight to 12 patients in a half a day. So you're seeing like 16 to 24 [00:06:00] patients and a full day.
[00:06:01] And this is again, inner city DC. Most of the patients, are not necessarily English speaking and, or have multiple problems. So you're trying to deal with, as a family physician, patients with diabetes and depression and or patients with high blood pressure and high cholesterol and HIV. And there's so much that you're trying to deal with in such a short period of time.
[00:06:19]And it was at times overwhelming. I absolutely loved to doing the work, but I never felt like I was able to truly care for the patients the way that I think they deserve to be cared for. I can only do so much in a 15 minute visit and I would have to, so we need to come back, make a follow up appointment for this, knowing that for the patients that we serve.
[00:06:36] Taking time off for an appointment might mean not getting paid that day. So I always hesitated because I didn't want them to lose it, lose that funding. And then I did that for a few years before I became medical director, as I said, two community health centers in Washington, DC that were actually sponsored through Catholic charities.
[00:06:54] So through these health centers sponsored by Catholic charities, we actually saw an entirely [00:07:00] uninsured, poor population of people. And it was this experience that first opened my eyes to the whole concept of patients paying directly for services. Because even though our patients were a very limited means, we did ask patients to make a contribution to their care for their visit.
[00:07:18] And more importantly, we had negotiated with labs to be able to provide laboratory testing at significantly reduced costs. And a lot of the national laboratory chains were willing to work with us. If we ordered a lab, we pledged to pay that at the price that they quoted us. So I discovered that I could get a cholesterol panel for $4 or a complete blood count for $3 and 25 cents or a thyroid stimulating hormone test for $8.
[00:07:46] And I thought to myself, how is this possible? I remember when I went to the doctors and had a complete blood count done, it was $80. My father used to send me his labs and his bills and, a cholesterol test would cost him 60 or $75. So [00:08:00] this is the first time that I learned that when you pay directly for care, whether we as a clinic paid the lab directly or patients pay directly for their care, the cost was so much less.
[00:08:10] But the value is so much greater. So when patients would make, a small contribution to their care, they were investing in it, the knew they wanted to understand fully they wanted to get at the root cause. I'll never forget having a conversation with a patient once who had some early signs of liver disease and I had tested him for hepatitis and as it turns out, he was negative, which was fortunate, but he actually never been immunized for hepatitis B.
[00:08:38] And so I talked to him about the importance of giving him the hepatitis B immunization, because given his underlying liver disease, if he contracted the infection, it could significantly worse than this condition and result in much more severe healthcare consequences. And I remember having the conversation that the vaccine was going to cost him $80, which may not seem a lot of money to some people, but for this person [00:09:00] who lives paycheck to paycheck, it is a lot of money, but we have. The luxury of having 30 minute visits with patients. So I could take the time to explain like, yes, this is an investment now, but what, this could save you down the line could be dramatic.
[00:09:15] Like not only from a financial perspective, but this could literally save your life. And so he understood and was willing to make that investment in his health, on, in contrast, I remember seeing patients at my previous clinic who came in with insurance with a headache and they were like I need an MRI.
[00:09:31] I'm like, would go through you actually don't need an MRI, but will you just get it anyway? Because like my insurance is going to cover it. And so there's this mentality. If I don't have to pay for it it doesn't matter if I really need it or not. I want it because I'm already paying insurance.
[00:09:45] So I want to make the most of my insurance. And it's just a very different experience when patients are paying directly. Now, can I just make a comment about providing direct care to the poor? Because I think this is oftentimes seen [00:10:00] as one. The biggest, this was one of the biggest myths that direct primary care is concierge medicine, which to be very clear, direct primary care is not concierge medicine.
[00:10:11] They are distinctly different, but because of the association, a lot of people think that direct primary care is really limited to people of means people that would otherwise be able to have access to insurance and can afford to pay this out of pocket monthly expense for their additional luxury care.
[00:10:28] The reality is I'm sure you can link to this in your show notes. The average cost of direct primary care for a monthly basis is oftentimes less than $100 a month. And maybe even less than $50 a month, depending on, the age of the patient or the location, there's a lot of factors that go into it.
[00:10:46] But I learned through my work at Catholic charities. Even poor patients can benefit from this. And in fact, I wrote two blog posts about providing direct primary care for the poor. And these were published again, my husband, [00:11:00] Dr. Kenny Lin has a blog called common sense family doctor. And he posted these as guest posts on his blog.
[00:11:06] When I wrote them 7, 8, 9 years ago. And they were some of the most popular posts because I debunk the myth that direct primary care is for a limited selection of the population. Direct primary care really can be and should be for everyone.
[00:11:23]Dr. Maryal Concepcion: [00:11:23] I'm really glad that you brought that up because that is a big worry for some people when they are coming from a practice that's very heavily populated by Medi-Cal or Medicaid.
[00:11:34] And so it's really wonderful to hear you say that. When your patients in Catholic charities came to see a provider to see a doctor, did they pay cash for that visit because they had
[00:11:46] Dr. Marguerite Duane: [00:11:46] no interest.
[00:11:48] Yes. So all of the patients that we served were uninsured, and to be very clear, we did not charge them a visit fee. We asked them for a contribution for their care. We always, as a standard, ask them to contribute [00:12:00] $40 for a 30 minute visit. So at Catholic charities, it wasn't a true direct primary care membership practice because they did not pay a monthly membership fee, but they would make a contribution when they came.
[00:12:10] Now, if the person didn't have any money or they only had $10, we accepted whatever they were able to offer. And we never turned anyone anyone away. But what was astounding, what I found was amazing, like on average, we collected $32 per visit. So 80% of what we requested again for a 30 minute visit. Now, some people would argue that's terrible because you could get reimbursed from, insurances at a much higher.
[00:12:38] I had zero people who did billing that worked for me because we didn't bill. And there's a huge cost when you have to have front desk staff and billers that you're paying simply to try to collect your fees. Literally the woman that would schedule the appointment would be. We ask a $40 contribution, what are you able to give today?
[00:12:55] And patients would simply give what they were able to give. And that was it, so there was no like keeping [00:13:00] track or sending follow-up bills. And, but because these people really valued their services, they actually wanted to make a contribution. They didn't necessarily want to just get it for free because they realized there was value in that service, through Catholic charities, we were able to supplement the services that we provide through grants and through donations.
[00:13:17] So we certainly didn't subsist solely on $32 per visit. Again, I would argue that through direct primary care, there are ways to serve people at every level. There's the, there is the practice in Modesto, California that is often referred to as the Robin hood practice. I believe at St. Luke's family medicine, in which they have some patients that pay extra each month to help cover the costs of those that may not be able to pay the full amount.
[00:13:43] So people know like I'm paying a little extra, but it's actually going to make sure somebody else can get the same kind of high quality care for Ms. Family medicine practice as I receive. And one of my early inspirations in direct primary care was Brian Forrest. And I remember he had that option as well.
[00:13:59] Like you can make [00:14:00] a monthly donation to cover the fee for a patient that might not be able to pay. And I think there are a lot of innovative ways that we can provide direct primary care to a broad swath of the population. First is we keep our patients. Very low. I tell my patients when they sign up for modern mobile medicine, they can expect to pay for their direct access to a doctor, including up to four house calls per year for an individual, what they pay for their cell phone bill.
[00:14:27] And I'm like, if it's worth it for you every month to lay out less than a hundred dollars. So you have your cell phone when you can call anybody at any time, isn't it worth it to lay out that same amounts you have direct access to your doctor via their cell phone, literally at any time. And patients are actually astounded that's all that we ask for.
[00:14:46] And we even have family plans that again, it's like the family plan that I pay for me and my husband and my mom. Who's on my cell phone plan. It's about the same as what families pay to have me as their direct primary care doctor.
[00:14:58] Dr. Maryal Concepcion: [00:14:58] And I love that though, because as you're [00:15:00] talking about innovation, it's also important to have to be able to explain it.
[00:15:06] The model and explain the value that is not at a concierge cost to patients who might not be familiar or might be hesitant because they think it is concierge medicine. So the idea that you're explaining it as a cell phone bill, simply some people use Netflix or gym membership. I think that it's in our favor to use those types of comparisons because it really makes DPC more understandable because even though the phrase direct primary care.
[00:15:35] A lot of people don't even know what a primary care
[00:15:37] Dr. Marguerite Duane: [00:15:37] physician is. And, I want to be clear because yes, I'm a huge believer in direct primary care. And I use the acronym DPC to refer to direct primary care, but it can also be translate into direct pay care because it doesn't only have to be limited to primary care physicians.
[00:15:53]In fact, psychiatrists have been doing this for decades because I got most psychiatrists don't accept insurance. Like they expect that you're going to pay, [00:16:00] directly for your services. And we're seeing this more and more as doctors are realizing, and this is an important point to make that, close to half of all medical expenses actually goes to administration.
[00:16:10]People think doctors make a ton of money and we're spending all this money on health care and it's going to doctors. It's not, it's going to administer administrators. And I say this as a person. I know I talked about, I always wanted to be a doctor and I knew that without a shadow of a doubt.
[00:16:26] I actually graduated college a year early, after only three years. And I just turned 21 and thought to myself, am I really ready to start medical school and deal with, serious issues of health sickness and death at such a young age. So I actually decided to take a little bit of time off and I pursued a master's in health administration.
[00:16:44] So I have that perspective and that understanding. And again, it Catholic charities, I worked from the perspective of a health administrator. So I understand that role, but what I think is important to note is that so much in healthcare today, when we go through third-party [00:17:00] payers, so much of that money goes through administering the payment and the receipt of services.
[00:17:05] It's not actually going for the care it's.
[00:17:08]Dr. Maryal Concepcion: [00:17:08] I find your journey so fascinating because starting with your sister's birth at home and your decision from that point on to become a doctor, and then seeing what you did serving the uninsured at Catholic charities and also serving as an administrator, you.
[00:17:26] You saw all of the reasons why DPC is the way to go before you even opened your DPC. I find that so fascinating
[00:17:33] Dr. Marguerite Duane: [00:17:33] and what's interesting is I have been a huge advocate and passionate about direct primary care long before I started my direct primary care practice. I first learned about it shortly after residency, probably around 2005, 2006, when it was still very much in its infancy.
[00:17:51]Again I remember. Reading the article about Brian Forrest and his practice in North Carolina, and then reading the article about the St Luke's practice in [00:18:00] California. And this was very inspiring to me. And so I, in 2008, when there was the whole debate about healthcare and healthcare reform and what are we going to do?
[00:18:11] I remember attending the American academy of family physicians, annual meeting. I've always been very active in the, in our academy ever since I was a first-year medical student. In fact, having had the opportunity to serve on the board of the AFP as a student member. So I've always been very active and very vocal.
[00:18:28] And in 2008 at the WFP meeting during one of their town halls there was a big discussion about healthcare reform and everything that needed to be done. But one thing that I did not hear them mention at all. Was direct primary care. And I brought it up because at that point I had learned about it. I was looking for more information about it.
[00:18:46] I went to the WFP website. There was nothing, zero zilch, anywhere about direct primary care. And I remember going up to the microphone and asking them we're talking about this bill, which I know all of you think this [00:19:00] is like going to save us. I don't see that as saving us. I actually see that as further damaging the doctor, patient relationship further inserting more people, more organizations, more government in between that doctor and patient.
[00:19:14] I don't think this is the way to go. Why aren't we having a conversation about direct primary care? Why is this not on the web? I said, I had to read an article in the family practice management about this Dr. Brian forest in North Carolina, but there's nothing else out there. Why aren't we talking to people like Brian forest?
[00:19:31]About this and little did I know Brian was actually there at the conference. He happened to step out, was talking to somebody and somebody who knows, there's a woman in there and she's like going on about direct primary care and she just brought up your name and I'll never forget, the president elect just didn't have anything.
[00:19:46] She's like, well, we're we're looking at all the models. I'm like argue because there's been no mention of this. Now I'm super excited and super proud that the WFP has really finally embraced direct primary care and [00:20:00] offers the DPC summit every year. And I think that's wonderful, but I also think it's really important to recognize the roots of that.
[00:20:07] So the people within the direct primary care movement really came together. Thankfully to the leadership of Larry Bauer, who is the CEO of the family medicine education consortium. So it was the family medicine education consortium, probably back in 2009, 2010, that brought together Brian forest and Erica bliss and other early leaders in the direct primary care movement to say, how can we take these bright ideas and these amazing practices and what you're doing and grow this, how do we take this and make it available?
[00:20:42] So more doctors can embrace these models. And I went to those early DPC summit meetings that were only sponsored by the family medicine education consortium. Again, years before I started my own practice, because I was so passionate about seeing. Movement grows. So it's just so exciting now to [00:21:00] see that, the bright ideas of family doctors Garrison bliss obviously is another one who really were very inspirational and brought this idea forward and brought it into reality could then be incubated and shared so that it's happening now all throughout the United States.
[00:21:18] So I'm grateful to the FMTC for planting those seeds. And I'm grateful now it's the American academy of family physicians for finally stepping up and sharing this with with all of their more than 100,000 members, because I think this is something every family physician should consider. Especially if they're feeling burned out or disillusioned with the current practice.
[00:21:39]Dr. Maryal Concepcion: [00:21:39] It's interesting that you say that because if for the listeners, if you haven't already visited DPC news.com, you should just put in your email and sign up for the newsletter because every week there's at least one new DPC practice popping up in our country. And, to your point that it has been [00:22:00] incubated and now shared, and it is growing like wildfire and specialists are even opening up, big surgery centers.
[00:22:06] Like I think there's one that just opened up in Indianapolis or it's about to open
[00:22:10] Dr. Marguerite Duane: [00:22:10] just like the one in Oklahoma. Yeah. In Oklahoma, the surgery center in Oklahoma is an amazing example.
[00:22:15] Dr. Maryal Concepcion: [00:22:15] And the idea that we are. As a community, really educating our patients about how a good primary care doctor can do effective medicine, just like you are doing in people's homes right now.
[00:22:32] So well. Oh, I see. I say right now, even though I know that you're physically not in DC, but we'll get to that. So now I want to ask when you were an advocate prior to opening your DPC, you're in DC, you're at Catholic charities. What was the point at which you decided to jump to open up your DPS?
[00:22:53] Dr. Marguerite Duane: [00:22:53] Yeah, so there were a few things that happened. Like I said, I became the medical director of Catholic charities in 2008. Literally my offer letter [00:23:00] was dated the day I gave birth to my second child. And I started just a couple months after her birth. And I worked there for a few years, working 60, 80 hours a week, overseeing it to medical clinics, to dental clinics and network of volunteers.
[00:23:13] Being a mother of two small children. So my life was very full. And then in 2012, I actually gave birth to my third child and I had fully intended to go back to Catholic charities part-time but I just, I had a moment of personal crisis where I just closed my eyes and I saw my children growing up and missing it.
[00:23:31] And I decided I don't want that to happen. And I made the decision in that moment. I obviously talked about it with my husband before I actually put in my letter of resignation, but I made my decision to leave my job and become a stay at home mom, which shocked people they're like, but you're a doctor.
[00:23:48] You're an object associate professor at Georgetown. You've got all these skills and these talents and I'm like, yes, but anybody can be somebody's doctor and anybody can teach medical students at Georgetown, but only I can be the mother to my [00:24:00] children and I really want to be there for them. So I made the decision to become a stay at home.
[00:24:06] Mom. My husband likes to joke. He would say, stop calling yourself a stay at home mom, cause you don't really, I stay home a whole lot. You are out and about, still doing lots of things. And at that time I had also started the other organization that I lead in addition to my work with my direct primary care practice.
[00:24:22] I serve as the executive director of facts, which is the fertility appreciation collaborative to teach the science. And it is also a project of the family medicine education consortium. So I started that in 2010. So 2012, I quit my job. I became a stay at home mom. I started growing my facts organization.
[00:24:40]But always with the intent, when I go back to doing clinical medicine, which I knew I wanted to do, it would only be through direct primary care. Couple of years later, in 2014, I reconnected with a fellow family physician, Dr. Matt Hayden, who I had. From a decade ago when he was a first year resident at the Georgetown family medicine residency [00:25:00] program, and I was one of his attending physicians.
[00:25:02] He was looking at starting a direct primary care practice. And I told him I was totally on board and I wanted to work with him to do that. So we met regularly. We met with a marketing person to pick colors and come up with names and we brainstormed, what are the ways that we want to do this? And I knew at this time I still want in my family, am I my role as a mother to be my top priority.
[00:25:25] So I did not want to be tied to seeing patients on certain days of the week, because if my child was sick, I wanted to be able to tend to them. If my child's had a field trip, I wanted to be able to go. So we had talked about the idea of actually starting a house calls only based practice. And I was very excited about this because if you are only doing house calls, you have no overhead of an office.
[00:25:47] So that sees probably the biggest expense that, that physicians, experience is rent, renting an office space. So Dr. Hayden and I, Dr. Matthew maiden and I, over a two year period from 2014 to [00:26:00] 2016, really, we laid the foundation. He had also gotten a business degree, so he was able to do a lot of the legwork, which I'm very grateful to him for.
[00:26:09] And we opened our practice in January of 2016. And the plan was for me to start enrolling patients and help to figure out the logistics. And at that point I had actually had another baby, my fourth in 2014. And so I still had two young children at home and I started seeing patients. And my goal was to enroll one new member a month, whether it was an individual or a family over the next 12 months.
[00:26:32] And I was successful in that goal. And it was an incredible. Opportunity and experience to finally, experience for myself, the actual Joyce of being a direct primary care doctor. So it was amazing. That's all I can say. It was just absolutely incredible and such a privilege,
[00:26:50]Dr. Maryal Concepcion: [00:26:50] especially after the journey that you've been on up to that point, When you guys were sitting in developing your model and thought about, doing a home [00:27:00] visit, an explicitly home visit model would be fantastic for both of us. Had you guys been exposed to any other DPCs that were doing exclusively home
[00:27:08] Dr. Marguerite Duane: [00:27:08] visits?
[00:27:09] So we were going to be the first, most DPC doctors will offer home visits. Some may include that in the fee, some may offer it as an additional fee, but we were the only ones that were going to do it exclusively as a housecall based model. And for me personally, since we started in January 6th, January, 2016, I have always only done house calls.
[00:27:31]As part of my practice, I've never had my own office space, but my partner, Dr. Hayden and I should be clear, like I was able to do that. And I do that because for me, I always envisioned being. I always, I joke about this. Like I always envisioned DPC as my side gig, I'm a mom, that's my first job.
[00:27:48] I'm an executive director of facts about fertility. And then on the side, I'm a direct primary care doctor. So I always saw being a direct primary care doctor as a 10 to 20% job [00:28:00] for my partner, Dr. Hayden he's the breadwinner in his family for him. He always wanted to do direct primary care, full time.
[00:28:06] And he discovered, and I think this is important to note within a couple of years, that it's really hard to do an entirely housecalls based med practice, full time for a whole variety of reasons. So he does have some patients that are members of modern mobile medicine and only received their Caribbean house calls and telemedicine.
[00:28:25] But he's developed a sister practice called pure primary care, which is an office based practice. And so he actually rents office space, I think two to three days. So he's able to accommodate patients, both in-person and at home. And he found that just worked best as a physician who wanted to do direct primary care full time.
[00:28:45] But yeah, when we started modern Mola medicine, we did not have an example. We did not know what to expect. Literally. I would go to playgroups with my kids and say, so digging about starting my own practice and coming to see you in your home and take care of [00:29:00] your kiddos. And some of my friends are like that's interesting.
[00:29:04] And others are like that's weird. And others are like, that's so cool. I got a mix of reactions and but it's very encouraging to see it's ironic because just this morning, I got a call from a person. With an acute symptom, severe pain. And she and her family were actually the very first family to sign up with my practice.
[00:29:25] And we knew each other because our boys were in the same preschool together. And so we would talk on occasion. And when I first told her about this practice model, she was like that's interesting. And I said to her today, I'm like, I just am still so grateful that after five years you were the one, you were the family that said, we're going to try this.
[00:29:44] Nobody else that we know has a doctor that comes to their house. But when she called me this morning, because she had woken up at five o'clock in the morning and severe pain, she was like, this is why it's worth it to pay you to be our doctor, because I literally saved her a [00:30:00] trip to the emergency room, which in the middle of Kobe can be even scarier, let alone, costlier.
[00:30:05] So it's just, it's so encouraging to see how it's grown.
[00:30:09] Dr. Maryal Concepcion: [00:30:09] with you mentioning that your goal was to add one patient or family a month, what number was your goal in terms of maxing out your patient panel?
[00:30:20] Dr. Marguerite Duane: [00:30:20] That is a great question. So I remember doing the research and at that time, what I learned was that most full, like conventional family doctors that work in a traditional office setting with a traditional insurance model, the expected size of a physician panel is anywhere from 2000 to 3000 patients.
[00:30:40]When I first did research about the direct primary care model, I originally discovered that most full-time direct primary care practices. We're 500 to 600 patients. So in my mind if I wanted to do direct primary care, 10 to 20% time, I thought to [00:31:00] myself, I would probably have a panel of about 60 to 80 patients, which many people may seem well.
[00:31:05]That's not really a lot. What difference are you making if you're only caring for 80 people. And I always like to talk about, there's a story. I remember reading once and you can appreciate this being from California about the little boy that sees all these starfish washed up on shore. And he's one by one, throwing them back in and someone says, how are you going to possibly help them all?
[00:31:24] He's I may not be able to help everyone, but I'm going to help with this one. And that's my feeling. I can't care for everyone. I'm a tremendous extra, and even I really couldn't care for 2000 to 3000 patients, in a traditional family medicine practice. If it was important enough to me and my focus was solely on patient care, I absolutely could care for 500 patients as a direct primary care doctor.
[00:31:47] But again, for me, what I love about family medicine, what I love about direct primary care is the flexibility. It gives me to be able to care for a group of patients, for whom the care I provide [00:32:00] is literally life-changing. I mentioned I have two patients that are going to give birth this year.
[00:32:05] Both who suffered from either long-standing infertility or recurrent miscarriages for more than one to two years. So I have absolutely changed their lives. So while I may only care for quote, unquote, may only care for 60 to 80 patients, I'm doing direct primary care. Part-time I know I'm absolutely making a tremendous difference in the lives of my patients and ultimate.
[00:32:27] As family physicians, that is what we are called to do to make a difference in the health and wellbeing and the lives of the patients we care for.
[00:32:35]Dr. Maryal Concepcion: [00:32:35] It reminds me of that idea that the world, you might be one person, but to one person you might be the world.
[00:32:41] Dr. Marguerite Duane: [00:32:41] I love that quote and that's so absolutely true. And one of the things that I've had to learn, because I think this is part of who we are as family physicians, it's part of our training and part of our mindset. We feel like we can do so much because we really can, but I also have to remind myself, even though we can do a lot, we [00:33:00] can't do everything right.
[00:33:01] And so it's really important to know our limitations. And for me as a physician, as a mother, I know my limitation is I can only care for so many patients because if it gets beyond. Then it's my family that suffers. And again, to me, that is first and foremost. So I want to make sure I have the time and I will tell you doing direct primary care for the last five years.
[00:33:22]Every time my children went on a field trip, I was always there to chaperone. Every time they had, a mom volunteer in the library, the kids would be like, she's here 10 o'clock on a Tuesday morning because I had such control over my own schedule. I could be there because I had the availability.
[00:33:42]And for me, as much as I love direct primary care as invigorating and fulfilling and rewarding, it is for me to serve as a direct primary care physician for my patients. If it begins to interfere with my family and their wellbeing or my work with facts and what [00:34:00] we are achieving there, then it's not worth it.
[00:34:02] So we have to find that balance. And for me, I have found that in the number of patients that I'm able to serve now,
[00:34:10] Dr. Maryal Concepcion: [00:34:10] as you were building up your panel, One, how quickly did you get there? And two, did you use certain benchmarks for yourself to feel out this is enough for me or no, I can take a little bit
[00:34:23] Dr. Marguerite Duane: [00:34:23] more on.
[00:34:24] Yeah, that's a great question. So again, as I was building out my panel that first year, the first year that I was building my panel, my goal was to enroll at least one member a month. And I did that. And the amazing thing is that I have actually done no advertising, like which some people are like, how are you able to grow your panel?
[00:34:44] It's literally been friends and family through my children's school, through my book club, through playgroups, through the moms group, through the church, through the local book club. It's literally been word of mouth within those [00:35:00] organizations in part, because. It's ironic. I worked in Washington, DC, the nation's Capitol, which is clearly a major city, but my medical practice is really a very small town neighborhood practice.
[00:35:13]I see my patients walking to school. I see my patients at the library. I see my patients at the local swimming pool. So my patient panel has grown literally through the people that I know. And it's been really encouraging, but to your question, are there benchmarks, were there things where it was like, I need more, I need enough.
[00:35:33] One of the things that I discovered is when I have a new patient enroll and I do a new patient visit, I always explain to my new patients when they schedule a visit with me that they need to block 60 to 90 minutes for that visit. Now they get a little quizzical because they think to themselves I thought with direct primary care, there is no waiting.
[00:35:51] Like I'm used to going to a doctor for a visit and it's an hour and a half to two hours because I wait for an hour and then I get to see them for a half hour. And I explained to them. When I say black, [00:36:00] 60 to 90 minutes, that's 60 to 90 minutes of FaceTime with me going through your history. Getting, in detail, if you're a diabetic, don't be surprised if I open your refrigerator to see what food do you have in here, what can I recommend you continue eating?
[00:36:14] What would I recommend you stop eating? So it's really comprehensive. But it's so incredibly valuable to be able to provide that service. However, it's also very time-consuming. So I discovered it did not work well for me to enroll new patients over the summer because it was more time consuming and newsflash over the summer, my kids are home and I didn't want to put my kids in summer camp all day, every day.
[00:36:39] I want it to be able to take them to the pool for swim lessons two mornings a week. And so I discovered I would enroll new patients in the fall and in the spring, but come June through August, I'd be like, can't take on any new patients, unless you're one of my patients. Then obviously I'm taking on that person as a new patient, but I would not take on those new patients.
[00:36:59]
[00:36:59] So, [00:37:00]
[00:37:00] Dr. Maryal Concepcion: [00:37:00] I have not heard anyone talk about strategically adding patients only certain times of the year. So I really love that. And as a mom with two little ones, I think that is going to be very useful to keep in the back of my mind as they grow up.
[00:37:15]Dr. Marguerite Duane: [00:37:15] Absolutely
[00:37:17]Dr. Maryal Concepcion: [00:37:17] As you were practicing and building up your panel, what communication tools were you using and what things would you have in your tool bag?
[00:37:25] Dr. Marguerite Duane: [00:37:25] So to speak.
[00:37:26] Yes. Literally what I did was word of mouth. So there were a couple of times that I would have a friend or a patient post to meet my doctor night because they would be talking about me on their neighborhood listserv about this great doctor that comes to their house. And the neighbors are like, wait, what she knows is that normal?
[00:37:44] That doesn't seem. What kind of doctor is she? And so I had a couple of patients. I've had a couple of patients that have hosted like a meet my doctor night. So they would invite me over to literally just talk about my practice and they would have their neighbors come and like they'd [00:38:00] serve, coffee and cake.
[00:38:01] And I would just literally talk with them about this is who I am. This is where I've trained. This is why I'm a family position. This is all the different kinds of patients that I care for. This is why I do this practice model. I'm like, you, I've got little kids. They're my priority. I want to balance my work as a physician, with my life as a mom.
[00:38:20] And these are things that are all really important to me. And those are probably like, if you talk about marketing, how did I market my practice? I Those were really the only. Marketing events that I did otherwise, it really was word of mouth. A couple of times I've actually donated a free house call for an auction night at my children's school.
[00:38:41]So that's another way for it to get the word out. And they're like, that's so cool. And I remember one year, the woman who did it she was so excited because they were doing a field trip that was going to be overseas. And so she needed to have a physical beforehand. And so that worked out great.
[00:38:55] I was able to get them the vaccines that they needed and they were very appreciative for all of that. It's really [00:39:00] just worked out well through word of mouth, whether it's through my patients, through my friends. I had a priest once call me and say there was a parishioner at our church.
[00:39:09] She's a single mom, she's having some issues. Would you be able to see her? Because she never, as a single mom, it was really hard for her to go to the doctor for herself. And and so I offered to do that and and it's, so it's worked out really well, my patient panel spans the gamut.
[00:39:23]When people hear that I do an entirely house calls based practice. They automatically seem oh, wow, that's great that you take care of so many old people in their homes. Actually, I have very few older people. I do have some, but it's not just older people that appreciate housecalls I think probably even more so are the families with lots of young children who appreciate the fact that when one kid falls and cuts open his scalp, like they don't have to pack them all in to go to the urgent care.
[00:39:51] Like they can call me and I can show up and take care of them. So I see patients from all ages, all walks of life. And it's just, it's really an [00:40:00] incredible experience. And
[00:40:01] Dr. Maryal Concepcion: [00:40:01] especially now during the pandemic, if you're a healthy young patient who just can't get in to see your doctor. And that is why you have to go to the urgent care. It's just, it speaks to how messed up our healthcare
[00:40:15] Dr. Marguerite Duane: [00:40:15] system is. Absolutely. And I will say like with the pandemic, I know, unfortunately for a lot of family physicians, their practices suffered initially, right?
[00:40:23] Because patients couldn't come in or they were afraid to come in. And insurance wouldn't pay if you didn't see the person in person. Whereas for me, my practice actually grew, I had new patients contacting me saying I heard that you'll come to my house and I'm terrified my son's got this infection on his finger and I don't want to go into the pediatrician's office.
[00:40:42]Is there any way you would do a house call? And I'm like, sure. And I looked up the woman's address, turned out. She lived around the corner from him. Like I didn't even have to get in my car. Like I literally picked up by a little medical bag and walked around the corner, to see this patient.
[00:40:55]The other nice thing about doing direct primary care, especially with a house called space practice is you can [00:41:00] find ways to connect with patients on many different levels. So one thing that I offer all of my patients is they can schedule a walk with your doctor and that's literally what it is.
[00:41:11] They can schedule 30 minutes to walk with me. Now, the one challenge with doing an entirely housecalls based practice is that there is no rate limiting step up. Am I sick enough? Is this concerning app that I really want to get up and go and see the doctor, go to the doctor's office with house calls, you get up.
[00:41:32] And he's I'm not that sick, but the doctor's going to come to me. So I'll just call any time. So the one thing that we discovered with direct primary care, where that housecalls based practices, we can not, we were not able to simply offer an unlimited number of in-person visits, right? So we set limits.
[00:41:47] So for an individual, they could see, they could get for house calls included in the course of the year. Really is what most at the most that people need or for a family that would include up to 12 house calls a year. [00:42:00] So literally I tell families, I can show up at your house once a month, all for the same low price.
[00:42:04] And they're like, that's amazing. I'm like, I know, but because I do limit the number of house calls I would offer for patients, you could schedule a 30 minute walk with your doctor and it did not count as a house call because my philosophy was, I need 30 minutes of walking, just as much as you do. So I'm benefiting from this already.
[00:42:21]And we can use this time to talk about whatever you want. I had some of my patients with depression scheduled a 30 minute walk just to talk. I mentioned the single mother who was my patient. She scheduled a 30 minute walk with me to talk about like sleep habits with her two year olds. Like how do I help my two year old learn to go to sleep?
[00:42:39] Nobody would schedule an appointment with their doctor to talk about this. And I said to her, to be honest, I'm going to share with you more from my experience as a mom and less as a doctor, but to have somebody that she trusted, that she knew really genuinely cared about her health and wellbeing made such a difference.
[00:42:55] I have an elderly patient with diabetes and obesity. He and I [00:43:00] regularly scheduled 30 minutes. Cause he like, it's the only way I can make sure I get my exercise. And he's no, you're going to show up at my door and we're going to walk for 30 minutes and people think it's crazy, but it's awesome.
[00:43:09] Again, I get to know my patients a little bit better. They're getting exercise. I'm getting exercise. It's good for everyone's health. It's just, it's really, again it's innovative. It's unique, but to me it's absolutely amazing. It just makes me
[00:43:24] Dr. Maryal Concepcion: [00:43:24] think of how you spoke earlier about your experience during your time at Catholic charities where, medicine doesn't have to cost a lot.
[00:43:31] And how much does walking with your doctor costs? Nothing.
[00:43:35]Dr. Marguerite Duane: [00:43:35] It absolutely is. Right. It doesn't It doesn't cost anything because again, we all should be walking 30 minutes a day. And if you can do that in a way that's going to add to it it's even better. I think it's it's a benefit and not a cost.
[00:43:50]Dr. Maryal Concepcion: [00:43:50] As people were signing up to be in your practice, did you geographically select people so that you didn't have to drive.
[00:43:58]To Virginia [00:44:00] or to far distances to to take care of
[00:44:02] Dr. Marguerite Duane: [00:44:02] patients. Great question. And yes, for anybody that's lived in the Washington DC metropolitan area, or frankly, any large city, that a one or two mile drive can sometimes take 20, 30, 45 minutes. And my time is valuable. I don't want to spend my time in the car.
[00:44:19] So when we, when I set up my practice, initially I limited it to my neighborhood in Washington, DC. I live in the Brooklyn neighborhood, which is where Catholic university is located. It's in Northeast DC and I extended from Brooklyn right over the border into Maryland and Hyattsville. So it's basically within a 15 minute drive.
[00:44:39] Now I don't necessarily drive 15 minutes into DC because again, What may seem like a 15 minute drive can turn into a 45 minute or deal when you're driving around trying to find parking. So I limited my practice to my neighborhood and the neighboring neighborhood, just over the border and Maryland. Now I would be open to seeing patients that live [00:45:00] outside, but if I have to drive outside of that route, then I do charge them a travel fee and I'm upfront with them.
[00:45:05] And I've had patients. I had an new mom who lived about a half hour in Bowie, Maryland. And she was having her fifth baby at home. And the midwife really wanted the baby seen. She just didn't want to take her baby into a pediatrician that soon. And so it was worth it for her to pay for me for six months and not only pay the membership fee, but then also pay the travel fee for me to come out and take care of her baby.
[00:45:28] Again, we try and keep those fees really reasonable, but it's to help compensate my time because it is valuable. So yeah, so we do, we did place limits, but honestly it's allowed me to have, again, what I consider a small town family practice and a big metropolitan city, which is absolutely just a unique experience.
[00:45:49]Dr. Maryal Concepcion: [00:45:49] When you describe, that it can take 45 minutes to go two miles. It's painful because I know exactly what you're talking about so especially thinking about how we transitioned [00:46:00] from residency to attendings you really do develop a sense as you're chugging along in your medical career, that our time is really. More than we think.
[00:46:10] And especially with you having four kids and doing direct primary care, I think that's really strategically smart that you looked at your radius of what you were comfortable traveling.
[00:46:22] Dr. Marguerite Duane: [00:46:22] Yeah, no, absolutely. I needed to do that again. It's all about maintaining balance. I think as family physicians, we need to model that for our patients, we need to maintain work life balance, and we need to, as physicians learn to say, it's okay to say, no, I cannot take on this one more patient.
[00:46:40] I remember at one point I had a family of eight that wanted to sign up with me. And again it happened, it was like June that they wanted to sign up. And I thought to myself, if I sign up this family of eight. This is going to take up like a significant amount of my summer just doing all of the physicals and everything.
[00:46:56]And what we did is, you know, I worked, it out with the mom that she [00:47:00] signed up initially because she was the one having the more immediate needs. It actually worked out well for her, for the family, because they saw, she signed up as an individual for a few months. And then in the fall she signed up the rest of the family.
[00:47:10] So I think we need to be very clear and just be upfront with our patients about what we are able and willing to offer and what they need. And, is there a commonality that we meet like, yes, what I am able to offer, we're meet the needs that you're presenting with. So I think it's important as family physicians that we achieve that work life balance and not feel guilty that we're not doing enough for our patients, because ultimately as much as I love my patients and I absolutely do.
[00:47:37] I care for them deeply. My family will always have to come first. They are my family and I am there. So I must prioritize them. And the beautiful thing is my patients know that people will ask me a lot. Like you give your phone number, you give your cell phone to your patients. Aren't you worried?
[00:47:55] They're going to call you at all hours. And the reality is I almost never get a phone [00:48:00] call between six and seven. It's somehow they know it's our dinner hour. And they're like, it's sacred. I rarely get phone calls after nine o'clock at night. Every once in a while I will, but that's because most of my patients know I'm usually up until midnight, so I don't mind.
[00:48:12]But they really have a respect because they know me as a person. I'm not just the doctor that like lives in the office. They know me. I mean, I'll never forget one time I had a patient call. Because her two year old has fallen off the bed and cracked, open his skull. And there was a laceration.
[00:48:29] He was like, I don't know what to do, can you come down? Do I need to run him to the ER? And I said, take it. She sent me the picture. I'm like, okay, that doesn't look so bad. The bleeding was controlled. I was like, I'm like, I am literally on my way to get my kids from school and I have to pick them up because if I don't, then that's not a good thing.
[00:48:47] And I said, so I can, I can grab my suture kit and throw it in my car and I can drive over like right from picking them up and just show up at your house. And a half hour, just know my kids are going to be in the car and she's that's fine. They can play with my kids. And I'm like, that's [00:49:00] great.
[00:49:00] And then when I was leaving the school, she actually called me back. She's you know what, it's actually, it's not bleeding right now. She's so if you want to bring your kids home and if you think you can come like in an hour or two, like that would be fun. I'm like, great. So I did, I brought my kids home when my husband got home, I got back in my car and I went over and took care of that.
[00:49:16] But again, like my, I work with my patients and my patients work with me to make sure like all of our needs are being addressed effectively.
[00:49:26]Dr. Maryal Concepcion: [00:49:26] What EMR do you use and have you ever changed the EMR that you have used for your practice?
[00:49:31]Dr. Marguerite Duane: [00:49:31] So as a direct primary care doctor does entirely house calls.
[00:49:35] I often get questions from friends or from colleagues. Like how do you keep track of your patient visits? Do you have any HR, do you use paper and pencil? And Mike, welcome to the 21st century. I have my lovely little laptop that travels with me. I've always used any HR with my practice. We initially started with one EHR.
[00:49:53] We use that for a couple of years, but they then rapidly increase their monthly rates. And so we ended up [00:50:00] switching to another EHR and current. Currently we use Serbo, which I really like. I think it's worked really well for us and for our practice. I love the patient portal to be able to communicate with patients via that route.
[00:50:14]So it's really, yeah. EHR is critical, I think to the work that we're doing, but what I love about the EHR is it's for me, it's for me to write down what I want to remember. I don't have to go through a checklist. I don't have to make sure I cross all these T's and dot all these I's
[00:50:30] so the insurance company pays me. I write down what I need to know to be able to truly take care of the patients in the best way possible. So the EHR doesn't have that sensation like it did when I was in a regular practice where it was so onerous, it's really a tool to facilitate the care that I'm providing for patients.
[00:50:49] And that's what an EHR should be.
[00:50:51]Dr. Maryal Concepcion: [00:50:51] 110% agree with you. It should not impede our ability to practice medicine. It should be able to, for me, the way I love [00:51:00] using any note on any type of EMR or, pen and paper like we used to is so that I can continue the story so that I can say, okay, this is what I did last time.
[00:51:10] These were my thoughts last time. Oh yeah. That reminded me. I needed to do this. Not, unless otherwise stated all other review systems are negative. Who the heck cares about that. Right. Now going back to your
[00:51:21] Dr. Marguerite Duane: [00:51:21] population,
[00:51:23]Dr. Maryal Concepcion: [00:51:23] , how has your church.
[00:51:25]Dr. Marguerite Duane: [00:51:25] It's actually amazing how many patients have stayed with me? Over the years. I, occasionally I've had some people sign up on a temporary basis. Mainly because. They need a doctor to help them with a certain situation for short amount of time, like the mom who had the newborn, and she didn't want to take them to a pediatrician those first few months, but overall, my patients have been pretty committed and I learned this and I really came to appreciate this last summer in the midst of, being a busy mom and having two jobs as a direct primary care doctor and as executive director of facts, I decided in the middle of a pandemic to go back to [00:52:00] school because why not add one more thing to my plate, but again, I'm very passionate about fertility and fertility awareness and restorative reproductive medicine.
[00:52:09] And I had the opportunity to do a research fellowship in women's health and fertility awareness in of all places, salt lake city, Utah, which is where I am currently, about 2000 miles away or three-day tri from Washington DC. And. I knew that would be a bit of a change for my patients.
[00:52:28] And so I really had to think through how I was going to introduce this concept and the transition and how I was going to plan for the continuation of care for my patients. And I talked about it with my practice partners. And what we decide is we agree to offer my patients three options with regards to their care one, they would have the option of switching to one of my practice partners over the course of the year, and that physician would take care of their needs.
[00:52:57] They would be the position that they would call or [00:53:00] text or message through the patient portal if there were any issues so they could switch. To another doctor for the year two, they could suspend their membership for the year and suspend their monthly payments. And then simply when I returned at the end of the year, they could then re sign up with me without having to pay a new registration fee.
[00:53:19] And if they needed any care in the midst of that year, they could contact me for a telemedicine visit or see my partner for a non-member visit. And then the third option is we do give my patients the options that they could continue their care with me with the understanding that 95% of that care would be via telemedicine and.
[00:53:41] Much to my pleasant surprise. Over 90% of my patients decided to stay with them to me through the year that I moved to Utah, which has been incredible. And it just, it really means a lot, we've developed such good therapeutic relationships that it was worth it to [00:54:00] that. Now I have made a couple
[00:54:01] of
[00:54:01] Dr. Marguerite Duane: [00:54:01] trips back, we moved out here in July and I made a quick trip back in August.
[00:54:05] I made a trip back in January because I had a few patients have babies in December and I'm making another trip back here in a couple of weeks, again, to see some of those new babies that that are my patients. But it's been really encouraging that, you know, when people find something that they really value and you provide a service that they really value it's worth it.
[00:54:26]I mean, Honestly, this is one of the other benefits I think of the pandemic is it really showed people like how much you can do via telemedicine. So it's been incredibly helpful. And again, it think it reflects the old adage that we learned in medical school, that 90% of the diagnosis is the history.
[00:54:43] And you don't actually need to be physically with the person to get the history. If you can get a really good history you're oftentimes able to address the patient's healthcare needs. Now there've been a couple of times when I've had to have one of my patients seen by one of my partners.
[00:54:57] And, that's one of the nice things about being in a practice [00:55:00] with other people that you, that were able to arrange that. So it's worked out really well for us and for me, and I would dare say for my patients, what honestly has been absolutely astonishing to me, not only the fact that my patients stayed, but yeah, Since I have been in Utah, my practice has continued to grow.
[00:55:22] Meaning I have patients still contacting me asking if they could sign up with me as a new patient. I'm thinking you do realize I'm 2000 miles away. Um, Because I actually did not get a medical license in Utah. I am not seeing patients at all in Utah. I'm only licensed in the states of Maryland and then in DC.
[00:55:40] But but yeah, I've had new patients and these are primarily patients who do have fertility issues or reproductive health issues, and really want to work with a physician that is trained in these methods. And unfortunately, or sadly, I am the only physician in Washington, DC that is [00:56:00] trained in using fertility, wearing space methods and the female cycle chart as a diagnostic tool to employ a more restorative reproductive approach to the care of patients.
[00:56:11]I want
[00:56:11] Dr. Maryal Concepcion: [00:56:11] to ask about that because as a Creighton blue Jay that was definitely reproductive health via natural. Methods was definitely something that we were trained in as part of our curriculum. So you've mentioned facts and you've mentioned your fellowship in Utah.
[00:56:25] Can you tell us more about facts and about what you're doing in your field?
[00:56:30] Dr. Marguerite Duane: [00:56:30] Absolutely. So again, fax stands for the fertility appreciation collaborative to teach the science. And we are a project of the FMI sea. And our mission is to educate medical students and nursing students and pharmacy students, and midwifery students and medical professionals, physicians, and doc nurses and natural paths about the science underlying natural or fertility awareness based methods.
[00:56:57] Not only for family planning purposes, whether [00:57:00] couples want to use a more natural method to prevent pregnancy or. They want to use a method to help them achieve pregnancy. I like to say fertility awareness based methods are the only true methods of family planning, but also using fertility awareness based methods as a tool, both to monitor their reproductive health as well as to address their reproductive health.
[00:57:18] So I saw a patient this morning, a woman in her thirties who is single, she's not sexually active, but she has a history of PCLs and painful periods and PMs. So I was able to do a visit with her. And she's actually one of the new patients to me this year, despite the fact that I am 2000 miles away.
[00:57:37] But fax is my way of sharing what I have learned training. I'm trained as both a Creighton medical consultant, as well as a femme medical consultant and a Neo fertility medical consultants. It's my way of sharing this information with my colleagues. So we offer a medical school elective that's approved through Georgetown university.
[00:57:58]And this year alone, we will educate over [00:58:00] 200 medical students. We offered a virtual conference in the fall in October, and we will be offering another virtual conference. This may, May 14th and 15th, and pretty soon we're going to be releasing an online CME course for medical professionals who want to expand their knowledge.
[00:58:16] My decision to do this research fellowship is one of the challenges in the fields of fertility awareness and natural methods is that there's so little science behind it. There's so little research that's been done. There's good science behind it, but there's been very little research that's been done in part because there's no real moneymaking thing here.
[00:58:34] It's women literally learn to observe the signs of their cycle and track it, whether it's on a piece of paper or an app. But physicians who are trained in these methods can use that information to really help improve women's healthcare. But unfortunately there's still very little research being done in the field.
[00:58:49] And, I had that idea it was the same thought I had when I started fax I had the opportunity to teach a class at Georgetown. And I thought to myself, when I was medical director of Catholic charities with two small kids working [00:59:00] 68 hours a week, like sure, I'll create an eight week course to teach to first year medical students.
[00:59:05] Like I've got time. I didn't really, and I wanted to delete the email, but I had that thought of like, well, if not me, who's going to teach these first-year medical students. And if not now, when I never learned about these methods until I was a first-year family medicine resident at Lancaster general, I thought that to myself when it came to starting facts.
[00:59:25] And I thought that when I had the opportunity to do this research fellowship, yes, it was crazy as a midlife crisis experience to move my family across the country, in the middle of a pandemic to go back to school and do a fellowship to do more research and fertility awareness. But my thought was, if not me, who's going to do this.
[00:59:41] And if not now, when it's not like I'm getting any younger and it's not like there's not a need for this research. So I decided to do this research. And the wonderful thing is I can see it's already not only impacting my work with facts, but it's impacting the care that I'm able to provide my patients.
[00:59:57] And I'm really just incredibly grateful that [01:00:00] my passions really align.
[01:00:02]Dr. Maryal Concepcion: [01:00:02] That's wonderful. And the idea that, it goes back to how meaningful you have been to your patients. Can you imagine, you know what this patient who you just mentioned this 30 year old, who. Has PCOS and has the desire to know more about her body, that you were there for her.
[01:00:21] And like you said, you don't have to physically be there in person. And if you needed her to see somebody for, you know, a blood draw or a physical exam, you have somebody who's an extension of you 2000 miles away.
[01:00:34]Dr. Marguerite Duane: [01:00:34] It's interesting, obviously I'm extremely passionate about direct primary care and I've been a huge advocate for, more than 15 years.
[01:00:41] And clearly I am an absolutely passionate about fertility awareness and I love it and I love sharing that knowledge, but it's funny because some of my friends in the DPC world, they don't quite get what's the root of my passion for fertility awareness and my friends in the fertility awareness world.
[01:00:56]They're quizzical about my love of direct primary care. [01:01:00] To me, there, there are two sides of the same coin, right? Direct primary care is about reestablishing and restoring that doctor patient relationship and by the patient paying directly for your services and you taking the time to really talk to them and educate them and empower them to care for their health.
[01:01:20] It's what it's all about. It's taking the time to empower your patients to care for their help with fertility awareness. It's the exact same thing, except it's a little bit more focused. I'm taking the time to educate my patients about the way their reproductive health system is designed to function.
[01:01:35] I'm taking the time to teach them to monitor the symptoms I'm educating them and ultimately empowering them to care for their health. So both of these passions of mine really aligned beautifully because they're both about educating and empowering our patients to maximize and achieve the best health they can.
[01:01:55]Dr. Maryal Concepcion: [01:01:55] Now, when you go back to DC, when you go back home, [01:02:00] will you be continuing to teach at Georgetown in addition to this online course that you're mentioning?
[01:02:06]Dr. Marguerite Duane: [01:02:06] Actually, so I, when my husband and I first moved to Washington DC in 2004, I joined the faculty then and I actually ran the third-year family medicine clerkship and directed the fourth year electives for one year.
[01:02:18] But when I left to become medical director of Catholic charities, I actually left my paid position at Georgetown and became an adjunct associate professor. So all of the teaching that I do for fax through Georgetown is all volunteer. So when I go back I will continue to teach. The fertility awareness elective for women's health and family planning, but I don't expect that I'll teach in any other capacity.
[01:02:42] I do occasionally give a lecture on direct primary care. I think that's really important, but otherwise I honestly just don't have the time to volunteer any more of my time to Georgetown, but but the great news is the elective that we have has just exploded. Again. We have been offering it as an online [01:03:00] elective since 2017.
[01:03:01] So when the pandemic hit, we were already prepared to continue to offer it. And we saw enrollment explode. And the amazing thing is so many students who didn't have the opportunity to go to Creighton or didn't have a resident like Dr. Wong when I was a resident Lancaster. Who've never heard about fertility awareness, like they're learning about it and it's literally changing their whole approach to women's health care, which is awesome.
[01:03:23]Dr. Maryal Concepcion: [01:03:23] When you're either teaching students or through this course, or when you're talking with your patients, are there any particular tools, like you mentioned, you can use pen and paper or an app, but are there any particular tools that you recommend to address their fertility goals or to help with national family?
[01:03:43] Dr. Marguerite Duane: [01:03:43] Great question. So I am a firm believer that it's always best for women to learn, to chart their cycle from a trained instructor. It's like driving, you can read a book about driving, but it's always good to learn from somebody that has experience and then can guide to guide you through.
[01:03:58] So I always encourage [01:04:00] women to learn from a trained instructor. One of the challenges is there's actually many methods out there, many evidence-based natural methods that most physicians, frankly just are not at all familiar with because it's not routinely taught in medical school. In fact, the research shows that only three to 6% of family physicians and OBS are knowledgeable about these methods.
[01:04:17] So I always encourage women to connect with a trained instructor and through our facts website, we link to educators and medical professionals. Some women like to track their cycle with them. Vacs did a review of apps a few years ago and found that most apps were actually not evidence-based. So I like to tell women, you are smart.
[01:04:36] You are smarter than your smartphone. Learn to make those observations and interpret them based on your understanding. And if you want to use an app, use that to facilitate tracking, but don't turn to the app to tell you when you're fertile and when you're not like, better. But we do, we, based on our review, there were a handful of apps that we would recommend, and I can share that link with your listeners from a direct primary care [01:05:00] standpoint.
[01:05:00] I think the best thing is to have a good laptop with a great EHR and a good cell phone. Really important. I like to use tools like visual diagnosis, which is great to be able to. You get a better sense when a patient uploads a picture of a rash to the patient portal so I can see what this might be like.
[01:05:14] So there's a lot of tools out there, but from a fertility awareness perspective, again I encourage people to visit our facts about fertility.org website for more resources and questions. We have webinars for patients as well as medical professionals.
[01:05:28] Dr. Maryal Concepcion: [01:05:28] Having heard your story, if a person is considering doing a home visit model, what are some tips that you would recommend they do prior to opening?
[01:05:39]Dr. Marguerite Duane: [01:05:39] I think that's a great question. if a fellow colleague was considering doing a home-based model, I would first ask, encourage them to do an assessment of their neighborhood and of their environment. And is there a need again, I don't know that my neighborhood could have supported a full-time direct primary care house calls doctor, but that's not what I was looking for per se.
[01:05:59]So [01:06:00] I would encourage them to just do a needs assessment in their neighborhood. One of the advantages that I have is one of my former colleagues at Catholic charities actually has a small clinic in my neighborhood. Having access to a small clinic in the neighborhood has been great because it's given me the opportunity when I do need to see patients for a procedure as an example, like I can use that space.
[01:06:20]As I mentioned, my partner also rents office space. So there are times when it needed to, I've been able to do that. So I would try to assess, is there a local physician or other medical practitioner that might have space, if you did need to use an office space? I'm probably the only visit I don't do in the house or are well-woman exams and pap smears.
[01:06:39] Like for those, I do, use the space that my, my partner rents out to be able to do those. So I think it is important to have some access to space. And then, geographically, it's going to be different. Like I limited my driving distance to a much narrower distance because of traffic in DC.
[01:06:56] But you may be able to expand your distance a little bit more. It's really up to you [01:07:00] and what's your comfort.
[01:07:00] Dr. Maryal Concepcion: [01:07:01] And that said, if others want to learn more or they want to discuss a home visit model further, what's the best way to reach out to you after this podcast?
[01:07:10]Dr. Marguerite Duane: [01:07:10] That's a great question. If people are interested in learning more about direct primary care and in particular about my direct primary care practice, I would encourage them to reach out to me, to my practice address at drduane @ at M med dot care. If they are interested in learning more about my work with fertility awareness and facts about fertility, they could visit the website facts about fertility.org, and they can email me@infoatfactsaboutfertility.org.
[01:07:40] So that's Dr. dwayne@mmmed.care or info@factsaboutfertility.org.
[01:07:47] Dr. Maryal Concepcion: [01:07:48] Thank you so much, Dr. Dwayne for joining us. Thank you.
*Transcription prepared by AI so there may be errors.
留言