Updated: Dec 19, 2021
Dr. Niran Al-Agba (Pronounced Niran like "Duran Duran" Al-AJba) is a third generation board-certified Pediatrician in private practice in Silverdale, Washington, a practice that has been open since 1971 before she was born!
She earned her medical degree at the University of Washington in 1999. She then went on to complete her pediatric residency at the University of Colorado School of Medicine/Denver Children’s Hospital in 2002.
Dr. Niran Al-Agba shares her story as to why DPC was not the solution for her. She shares how her practice is ideal as she has relationship-based medicine, charges for non-covered services and one works 20 hours a week while managing being a Mom to four as well as an author of numerous newspaper articles, blog posts and recently, she co-authored the book "Patients At Risk" with Dr. Rebekah Bernard. Honoring transparency as well, Dr. Al-Agba's story really highlights similarities between her clinic and a DPC practice and demonstrates that DPC is not the answer for some and that's ok.
Resources Mentioned by Dr. Al-Agba
Patients At Risk The Rise of the Nurse Practitioner and Physician Assistant in Healthcare a book by Dr. Al-agba and Dr. Rebekah Bernard
The Patients At Risk Podcast hosted by Dr. Al-agba and Dr. Rebekah Bernard
Kitsap Sun Innovation with Covid PPE storage article HERE
KevinMD post about Covid testing in patient’s homes HERE
KevinMD article addressing Single payer systems in Canada and Cuba HERE
KevinMD Article addressing Physician shortage HERE
Talking with kids about Covid HERE
Tribute to Piper Lowery, Dr. Al-Agba's patient HERE
Article about Dr. Rebecca Lee Crumpler HERE
Twitter Handle: @silverdalepeds
Direct care means to me that I'm getting to be up close and personal with my patient so there's no one else between me and my patient. I'm Niran Al-Agba of Silverdale Pediatrics and this is my direct care story.
Welcome to the podcast Dr. Al-Agba
Thanks for having me. I'm thrilled to be here.
definitely my pleasure now for the listeners.
I wanted to address that you're not doing a DPC practice and you're on my DPC story, but I wanted to acknowledge that on the DBC docs Facebook group, because you are someone who is extremely passionate about quality care for all Americans, you had posted. In response to somebody's post on the DBC docs, Facebook group, about the stressors of a DPC practice and how to handle those stressors.
And I found it really interesting, and I feel that this is how the podcast is being inclusive, that you were presenting an opinion from a doctor who is doing a micro-practice, who takes insurance, but still does direct care because you are extremely involved in your patient's lives and your family's lives.
And you in your blog post, you have a picture of a fourth generation baby in your practice. And I think that's amazing. So thank you so much again for coming on and sharing your direct care story. It's not necessarily pure DPC, but
that's okay. Yeah. Thanks for having me at that post. I felt so bad for the poster per se, because she was just really struggling.
And I think it's people don't realize how hard it is to run a business. And that's why I think I ended up in some of the DPC groups because I have a lot more in common with the DPC practice than people would think. And far less in common with someone who's running like a big private specialty group practice, simply because I'm on my own.
So I think that's why I ended up doing those groups, but I also learn a lot and I hope I'm supportive of people in those groups because I think we have a lot of. Absolutely. And
I think that when you say support, especially after 2020, and the divisiveness that we've seen as a country, I think that just the idea that everyone has their own opinion, but if we can support each other to create a field where it's okay to say things like I'm really stressed or I'm scared, especially when it comes to a DPC practice or medical practice in general, I think that's really amazing.
And I know that when I was speaking with Dr. Whitney, pat, that was one thing she noticed too, when she was closing her practice, she was able to go through those thoughts about, gosh, how am I going to, how am I going to get support on a Facebook group where everyone, it seems like a lot of people are DPC or die.
And I definitely get like that too. But at the same time, I really feel just being there to be even an open ear when someone is in a position where they're like, like you did w in a position where someone is stressed, somebody like yourself can say, Hey, it's okay. And let's take a step back. And let's think about why.
Yeah, there's the expression about there's more than one way to skin a cat med medicine is that way, right? If you just take a common condition, eczema, whatever, and there's so many different ways to treat it right. And the same, thing's true of, I think medicine, you need to find the system that works. And so DPC is an answer.
Like it's a tool in the toolbox to fix medicine. I don't think it's the only answer. I think it's a large part of the answer. And so I think that's a really important, I think for some specialties that doesn't work or scale as well as it does for say family practice or someone who knows emergency medicine or internal medicine.
I think those specialties that really scales well to go into DPC. It's a little bit harder when you have a narrowed amount of the population. So zero to 21, in my case, it's a little bit harder.
Now I wanted to go back into the history of the practice because the practice was opened by your father and with you growing up, basically after had opened the practice, how was life for you as the daughter of a pediatrician in a fee for service.
So it's interesting. And to be clear, he was part of a loose group in our hometown for a number of years and they all owned it.
They owned the group. So it was a private practice. It wasn't called Silverdale pediatrics just yet. But then he decided to leave when I was about 10 and or nine or 10 and go out on his own because I think the management and the overhead, that was the time where they were starting to hire administrators and you really didn't want an administrator.
And so he really opened his own, like by himself solo practice then, but he took all the patients with them. They all, a lot of the old records that I still have, the paper records have the old moniker doctor's clinic on it, because that's exactly the papers that you took with him. So essentially he, I'm not sure.
I really knew much more other than my dad was a doctor. I took a tour of the hospital at five, which my dad helped arrange for my class. And of course that's when I decided I wanted to do this. The pathologist you gave that to her still lives in town and still sends me patients after all these years. So that's 40 years ago and I knew I wanted to be a doctor.
And then I got to be about nine. And my dad said, yeah, I want to be open on Saturdays and I need your help. You need to come answer phones. And he said, I'll pay you whatever. I probably made like $2. And, uh, and so I just would go in with them on Saturdays and it was cute because he had an appointment book and you'd answer the phone and he'd say, just tell him to come.
Don't worry about like certain appointment times. Just tell him to come on over. And the patients used to say to me, who are you? Is this his daughter? They could tell at nine or 10, I really didn't know what I was doing. And we still use the same stamper we use then practically, maybe not the same exact, but we still do the date stamp like the old days.
And it's still the same paper charts we had then that I used to pull. And then I, as I got older, I was balancing the ledger because that's generally how we used to bill. In those days, there were probably about five different major insurances at that time. And so we build we'd open the checks, we'd enter them, we'd bounce a ledger at the end of the day.
And I was even the custodian throughout high school. That's how, that was how I heard her money when I needed it. So I've done every job there is.
it's such an interesting perspective because you ended up going back to your father's practice, practicing with him for 16 years. And you had all of that experience going into your professional job as a doctor.
And I just, I want to ask when you were going through medical school and when you were going through residency, did you envision always going back to Silverdale or did you ever think about if I could do medicine, I would do it differently or I would do
it in a different location. It's a great question, because I often say, I think I'm not burned out because I'm doing exactly what I thought I would be doing when I was nine years old.
So what's so strange about that is working there. I understood kind of the law, not the medicine, but the logistics of what was happening. And so anytime I pictured what I would be doing, it was coming from my experience at 10 years old. So I will tell you, there were times during residency where I would get really fed up with all the kind of bureaucratic layers of stuff.
And I would just think, gosh, if I could just be in my own practice, it would be, I could do what I want to do and make these decisions. And I started a countdown in my second or second year, I think, and I was in the ICU and I'll never forget. One of the attendings asked me, so what would you do? And I said, 15 months, three weeks, and two days I'm going to do X, Y, Z.
And so it became a thing during residency that she just wants to get out of here. And I did a rotation with my dad that last year in the fall of 2001. And just to make sure I was really what I wanted to do, and I just fell in love with it. And those kids now that I saw then, or 20 I've had one come back and she's a mother now.
And so again, it was exactly what I grew up with and while I've changed it, but there's a little more business. There's a little more boundaries. It's, it's a little bit different than maybe when I was a kid. I feel really lucky every day still because I am doing exactly what I pictured. So I don't think I would changed it.
The idea that you saw your ideal practice, you were able to join it and you, your patients were already familiar with you or from over the years, that's the dream for a DPC clinic in terms of building that amazing relationship with patients.
And I just, I love the similarity.
Yeah. And I think that's why the whole point of DPC, which I think is such an amazing concept is that, you know your patient, right? Like you're, maybe I'm assuming you guys take the blood pressure. You do the Heights and weights. You do the urinalyses, you do all the things I give my own shots.
I've given every shot, practically that my patients have received for the last 20 plus years. And they're not afraid of you. They are maybe when they're three to five, but they get to a certain age. And I had a number of children. This Thursday, we gave 450 COVID shots at a public clinic. And I had a number of my patients who knew I was there and scheduled their appointments because the teenagers had this ownership.
They said only Dr. Elijah is going to give me my COVID shot. Otherwise I'm not getting it. And it's really cute that these kids feel that strongly about the relationship. Like it's not just the parents, it's the whole family. And so I think what's really important when you talk about healthcare, whether it's insurance-based or DPC based, it's actually person based, it's human being based.
And that's what's missing. When you think about a DPC practice, Mrs. Smith walks in that doctor knows Mrs. Smith. He knows probably how many kids she has, probably what number of marriage she's on, what meds she's on. He knows by he or she, sorry. He knows by the Mrs. Smith's expression. What's going on. And the beauty is I do too.
And some people have told me you can't have 3000 patients and keep those records in your head. And actually you can, I may not always remember if it was the right or left arm. They broke when they were skateboarding. But I certainly know they did a fracture of the radius when they were skateboarding five years ago, 10 years ago, 20 years ago.
And that's to me, what direct care is I can totally
relate. When I was in college and I was volunteering at child life at UC Davis, I still remember the 16 year old that I saw with cystic fibrosis, who sent me as kids with medical issues. We're all angels because we have to live regular life.
Like it's really hard because I want to go down the hall and see the guy who's down there, but we both have CF. So I can't really do that. And so we have to live our normal lives plus deal with these illnesses. So I believe that we're all angels and it's things like that, it's the complete opposite of a person is a medical record number. A person is a code. The relationship really drives the people who are passionate about
direct care. Wadel the kid you met the mom, let's say at eight and weight'll their child turns eight and looks like the spitting image of them. It is so weird and I'll walk in the room and I it's almost like I, I just have been taken back 20 years and also I was look at the child and say, look at the moms.
Do you see the resemblance? And they're like, no. And I'm like, oh wow. I feel like I'm looking at you 20 years ago. And it's amazing. It's, there's nothing. So cool. So cool. Love it. Now,
in terms of your practice, you even talked about the paper charts that you, your dad had, and now you still have paper charts.
So tell us a little bit about your day to day operations.
We've had the same transcriptionist actually, uh, since 1974, what's becoming a little bit difficult. Logistically is that the tape recorders are really expensive or hard to find.
So patients will look at Goodwill, I'll look at Goodwill. And then I have a guy who fixes typewriters actually in Bremerton and he is able to fix Dictaphones. So he kind of piecemeals them together and, and so far so good. And so the day-to-day operation, anyone who's over 65 is listening to, this has probably laughing right now because they're thinking, oh my gosh, this younger generation doesn't even know how this works.
So usually I work essentially nine to one every day and four days a week. And I'll see, 20 to 25 depending COVID was a lot slower. So maybe it's not as many. And then it takes one minute per patient. And so you essentially see the patient and either, sometimes in the room, I'll dictate in front of the patient or the kids really like it, they'll say, go get your tape recorder.
And then, or sometimes I don't have time to do it. So I'll do it after two or three have stacked up and then I'll dictate. And you just dictate, like you would, I guess dragon is the new thing now. And you just talk and you say, Susie Smith, this is what she's here for. This was her exam. This is review of systems.
So you go through it. That's it's one minute per patient. So I spend, if I see 20 patients, I spend 20 minutes or less documenting, which is unbelievable. And to me, that's, I guess the reason I stayed is I can't do it faster on a computer. And what I've said for years is I will move to electronic records when they are.
Then the original, right? The original was an index card. So normally you'd have a file box and the Smith family would be stapled together and every Smith member would have their own card. You'd write down. You didn't have to document you just say, strep throat, penicillin shot the date. That's it. You don't have to write all the stuff.
You have to prove that why you thought it was strapping, why you tested them. So that was the original. Then obviously we moved to transcription and we moved to dictation and some people still hand write. I have a locums doc who still hands write handwrites for notes. But again, it's not more efficient.
The index card is the most efficient than handwriting, not so much. And then dictation was the next, most efficient. And now we're going to go to computers. I've got to type all this stuff. It just isn't the same. And I see so many mistakes, but they import stuff from prior notes. And I understand why that happens, but mine's always fresh.