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Episode 67: Dr. Niran Al-Agba (She/Her) of Silverdale Pediatrics - Silverdale, WA

Updated: Dec 18, 2021

Direct Doctor

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.

She is a frequent contributor to KevinMD, blogs at and is Mom to four children and in her spare trimester is chasing them or is at her practice.

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


Websites: and Silverdale Pediatrics


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.


I just, I chuckled because I used to record myself singing on my dad's Dictaphone, that I, that he would bring home from work. And I thought it was the coolest thing to be on a cassette player on the living room stereo system. But when I was in superior Nebraska, and this was 2010, so not that long ago doing my third rotation, third year rotation.

I remember going to the transcriptionist, there were three of them and I would give them my Dictaphone and then they would type, but they would print

it out on sticker. That's right. That's what we do. Yeah. You can still buy the sticker paper. I still have to buy it. It comes on a roll. And then what she does is she prints it out and then she brings it in and we cut it and then we stick it in the chart. people have said so many times, like you're not gonna be able to do it. And I'm like, Ooh, is the EMR police going to come and arrest me?

What are they gonna do to me? And even when I get audited by the insurance, they say, well, just send the electronic records. I'm like, yeah, I don't have those. So they'll come. And they'll, they just have to scan the charts and then they have to take the notes. So I don't understand what the problem is. And I just, I never want to go in the room and type in a computer. I never even want to bring that darn thing in the room with me. I just want my stethoscope, my oldest scope and a pen and myself, and I always want to be, because what, the one thing I do want to say about eyes up medicine, which is what I talk about a lot.

When I ask a teenager, are you sexually active or has someone been touching you? Whatever difficult question. We all have to ask our patients. I know their answer by the inflection of their like face. So I'm like, okay, that's a, yes, you're sexually active. Let's move on. Yeah. I would miss that if I'm typing in the computer and it's sometimes so subtle, you can just see their expression or they look super embarrassed and I'm like, okay, they're probably not.

I say, okay, is that a no? And so it's communication. That's getting missed that I don't have to miss.

Yeah. Always wrote down on the face sheet, my visit, and then I would always dictate afterwards. But then in fee for service, when I graduated residency, in my rooms, I would have the bed between me and the patient.

And so I would pull out the foot bed, I would put foot tray, a foot rest and then put my laptop and try to type as I was looking at the patients, because if I didn't, I would spend six hours after clinic getting my stuff done. And with a toddler, I was, I sat there and I'm like, why am I doing the visit literally twice because I have to do it.

I mean, just like you're saying, if there were a smart EMR that people were able to use and replace our visit, great. And with people using AI, there's definitely leaps and bounds differences compared to what we had before. But at the same time, AI is not a human.

They just haven't replaced the original. So medicine, wasn't a, what I essentially, I say medicine because directly interacting with your patient is what practicing medicine is. There's no space for the computer. It's just like this big problem in the way. And then doing it afterwards, doing it next day, doing it, whatever.

It's not the same. And that's, I don't know that it will ever improve upon paper. And some people say, oh, but you get no interoperability or whatever. That is where you could get your notes from here. They're number one, they come in by fax number two half the time. I don't need them because I know cause the patient called me and told me, I just had to admit a kid with Kawasaki's disease.

No one has called me from the hospital. So I, and I it's what's funny is I sent the mom down with a diagnosis of Kiyosaki's disease. I hadn't done blood yet, but the kid really met all the criteria. And so who knows what the note's going to say, they're going to think they diagnosed it practically, which is fine.

But I already know what the problem is because the mom told me and she's telling me they're staying and she's telling me what's happening. So I don't even need the note to come from the hospital really to tell me anything. And that's the direct care. So the patient is contacting me directly.

Yeah. And it's sad because as a resident, I remember.

When I was in the ER, admitting people, I would always, especially when it was business hours, try to reach out to the primary care physician. I have never had that happen except for once in practice. And that was my old attending who called me to say, Hey, tell me about this patient. And so it's really sad when we look at where our healthcare system is today.

And when we look at patient safety, it's devastating that you have someone like yourself, who is the wealth of medical knowledge about a person and is not even contacted when a person is sick. Like for my own patients, if I have to send someone urgently via ambulance to the ER, or if I tell them like, you need to drive over there to the ER, I like speed, do my notes and hand it to them so that they can take it to the ER doctor, because I know they're not going to call me because I'm sure they're so overwhelmed or whatever the reason is.

But at the same time, it's like, here are the key pieces of history over the last five years that I've taken care of this patient as to why I believe that they need to be sent. 45 minutes away to your ER. So

yeah, it's I always call just to be clear, like I always call the ER yesterday, they had some like transfer center thing and the nurse who took the call, didn't ask any clinical questions at all.

Again, I always try and call. And one of my favorite stories is actually a kiddo who had an infected ankle joint. And I sent her over to children's hospital with this septic arthritis. And what's funny is the note comes in the next day and it says, yeah, doubtful septic arthritis. So I'm sitting in there thinking it's rheumatologic.

So two or three days go by and I'm thinking, God, I wonder what happened with this. I'm really interested to know what the diagnosis is. So I call the patient, they all have cell phones, so I just call them and the mom, it was so cute. I said, so it wasn't septic arthritis. What is it? She's I don't know what language you're speaking doc, but it was an infection in her ankle joint and they just got her back from the, or they just drained her.

And I was like, oh, you mean I was right. Oh, okay. I guess that note didn't come yet. And afterwards a great part of it is the mom had just started this job and she was busy and she said, I'm going to lose my job. If I go back traveling sick, it's a long way from us to children's hospital. She says, I can't go back there.

I don't have time. I got to go once a week. I was like, once a week, they drained your ankle. Like what? And she goes, infectious disease wants to see me once every other week. And then. I'm like, what are they going to do? So I called the clinic and one of the nurses says, Hey, they got to come back and see this PA in ortho clinic.

And I said, uh, wow. So what are they going to do? That's so amazing that I can't figure it out and said the ankles drained. Like w I, this makes no sense. He's the he's part of the team. And I said, lady, I'm the head of the team. I'll tell you what you have the surgeon call me. And when the surgeon does call me, I'll let him see my patient.

So it was this kind of tug of war. And with the orthopedic surgeon who just didn't even want to pick up the phone and tell me anything, he just had a whole bunch of people over there that were just going to make her come back seven times unnecessarily. And again, this is the point of fee for service.

That drives me crazy is that I actually, and so to DPC practices, we save money. I don't want to find a reason to see the patient. They're doing that at the children's hospital. I'm not doing that. I saw her once a week, once, and then maybe once every two weeks, twice, she didn't need any additional stuff and I can follow up a surgical patient.

And I remember thinking, this is the stupidest way to practice medicine I've ever seen, but with liability, with not knowing the patient, I get it. But for them, it's not a friend or I think of all my kids as my kids, my children, I have 3000 children. It's not the orthopedic surgeons, child, it's my child.

And that's the part that's missing is the ownership. And I don't mean ownership of a patient. Like I own them, but like ownership or a sense of duty. To your patient. To me, that's the most important thing. And that's what DPC Ana micro-practice have in common.

No, I want to digress a little bit in terms of, you mentioned a locums.

If you have somebody who is taking care of your panel, if you're on vacation or if you need extra help, how does that work with regards to the paper charts?

Same thing. So I have, I, when my dad died, that's when I really needed help. And one of the, I take care of actually the locum doctors, grandchildren, and she had just retired.

She's a family doc, amazing family doc, and her daughter convinced, convince her to come out of retirement. And so she said, well, I'll help you while you're overwhelmed. So you can find someone once a week. And so she comes in once a week and sees patients and she loves the paper. She was like paper, oh my gosh, sign me up.

And she loves dictation. Like she just fell right in step. Cause that's her generation essentially. And she really has gotten to know the patients pretty well over the last few years, but she didn't think she was going to stay. And I remember thinking, okay, I think she's going to love this place. So I'm just not going to Badger her yet.

And after about 10 months, she was due to renew her license. And I was really hoping she stayed and she said, I love this. This is the kind of practice I always wanted to be part of. And so I'll renew my license and if, and I, we go halves on her license and halves on her DEA. Gosh, I'm so lucky to have her.

And I just pay her hourly to work and she loves. She loves it. Now she's older. She didn't come in as much during COVID and I really wanted her safe, so that's fine. We just work it out as we go. And she's just a cool doc and she's taught me a lot of new things. So anyway, she just steps right in, and my notes are really easy to follow.

It takes you essentially 10 seconds to read the last note it's like right above it. It's it's about this big is smaller than my, the height of my face. And you can skim it. Assessment plan. You're done. There's no like sexual history or marital history and a five-year-old that you get from the ER. Now there's no like tobacco cessation counseling for the five-year-old and the drug and alcohol questions.

Like all that gobbledygook is just not part of my charts. It's the, it's an old soap note. And if they say last year I was seeing for this, she turns the page and looks at last year's note. It's so basic. And so it works really well. I haven't had any problem with it, with anybody stepping in.

I'm laughing so hard and I hope that my cohort, my former co-residents are laughing hard because we do these Saturday night live skits at the end of residency.

And that was one of the things we made fun of this, the idea that you just start rattling off heart, regular rate rhythm, no murmurs rubs or gallops. And then do you actually know what a rubs sounds like now? Because I think it's just rote memorization, then you're just dictating that in the, you don't actually know what that sounds


Yeah, it is. And if they do so much unnecessary stuff, it just, I think that's the biggest hit to our efficiency and then our ability to do what we need to do. And for me, it's like their chart is a baby book. I cut out newspaper articles when they're on the cover of the newspaper, I get really excited and I have a certain section for like media.

I had a kid who was a model for one of the local stores. And so I cut out his ad when it came in the mailer and keep it and date it. If I have, I keep their pictures. If they're pictures that fit in the chart and they draw me a picture, I put their age and their date so I can show it to them when they're older.

And they love to see nothing that the 18 year old wants to see more than their picture when they were three, what did they draw for me? And so it's like a living history or a living like book. And I was there for nearly every one of those stories. When a given chart over 20 years, maybe they were seeing two or three times by someone else.

There's almost nothing even to memorize. It's just, it's in there. It's just, uh, it's just part of who they are. Part of who part of my relationship with them.

How do patients have access to their notes?

Now that it's a legal requirement

for us. They didn't really put in anything about the paper charts. They have exempted us technically, but I don't like to do that because I want to be like, I don't want a patient to suffer because I'm staying on paper. I actually just let them take a picture of their note and they take pictures of the growth charts to show mom or grandma or whatever.

And a lot of people will say, you're going to get a hundred thousand dollar fine. So whenever they take a picture, I say now, officially, I'm supposed to tell you if your phone is stolen. You're breaking HIPAA or your records become accessible and they're like, oh my growth chart. Yeah. I'm super worried about that.

And so I usually just say my, my disclaimer or my caveat is take a picture. It's totally yours. I don't know why if I make you a copy and hand it to you. That's okay. But you taking a picture is supposedly not okay. I treat their record. Like it's theirs because it is there. So I'm not hiding stuff. I don't write silly things in there.

I really, they can look at it any time. And so that's how I treat it so they can absolutely, they won't have the note that same day. So that's really hard, but they can take a picture of a measurements or what I think is going on. And plus I discuss it with them anyway, and sometimes I'll write it on a post-it, but they can take a picture of what they signed for their chart, record their shots, whatever they can have it.

And then they can have a copy that same day. It's just the dictation. Won't be back till the next day. So that would be probably the only part I'm not able to comply on, but I'm pretty darn close.

And even with EMR is it sometimes takes longer than 72 hours to get all your charts done without having 3000 patients.

So one day is pretty dang good.

Now you mentioned you have a transcriptionist. Do you also have a.

No, I do all the coding myself. Again, this is the thing about the micropractice right.

They just came out with new coding rules and I took that little webinar on it to understand what the differences are. And then I code myself and a I'm happy to have occasionally insurers will look at it and say, Hey, this isn't really a visit. I think one of my favorites was my dad had always done a visit and then frozen molluscum, because that's how he was taught in like 1980 a code.

And one of the insurers came through in the early two thousands and said, no, that's just a procedure code. You don't even need to do a visit. Like you just circle the procedure, you save frozen and on you go. That's what I do. Like I don't need to build more than I'm supposed to bill. I don't really care again.

I just make sure that the coding matches the documentation. And then when it's even times, like when you do it by time and my medical assistant, usually when we know it's going to be a more counseling visit, we set a timer and we just come out and bill it that way. Yeah, I do all my own coding. And

do you see if you look at your practice over time, would you say that as codes changed, as the rules have changed, that you have gotten less compensation because of the.

So to a certain extent, yes. Especially Medicaid. So the Medicaid population I've always felt like I should serve Medicaid patients, just like any other patient meaning offering my services simply because the state paid was they subsidize my education. So I think I do want to say the state is getting a really good deal because I'm probably going to be at this for 40 years.

So I'm sure I have more than paid off the subsidies in the last 20 years already, but I'm not complaining. I have my Medicaid families. I think of everyone the same. I don't care what insurance you have. I care if you like your kids, I'm really not good with the parents who hate their kids. Like, I do have a judgment thing about that, which I am continually working on, but I essentially get paid less by Medicaid.

And I would say about probably a year ago, they decided to start downloading all the visits. Some of the insurers are doing this. And so I really called them up and said, look, it's, here's my bottom line. It's about a funny bottom line. I pay my childcare $20 an hour. And when everything shut down, I had to pay my childcare $20 an hour.

So they wanted to drop us from, let's say a 9, 9 2 1 4, which is a moderate kind of visit to $60. And if over exactly, if, oh, and it was like 87 or something, so they really pretty significant. At $87. If I see three Medicaid patients in an hour, I figured overheads about 70 to 80%. And so I figured I roughly take home maybe about $30 for that hour.

And when obviously you diversify, right? So you have, you don't just only see Medicaid. You have to be. And I have a wait list and I maintain a 10%. I used to be at 50%, but the affordable care act changed all that. And so now I can only be at 10%, but as soon as someone moves, I automatically get someone off the wait list to Medicaid and add them in.

I need to do my part just for all kinds of people. And so, anyway, I'm at the point where it was gonna be $60 now with overhead, I was making $18 an hour. If I saw let's say three in an hour. And so I wrote a letter to my patients and I just said, look, here's the bottom line. If I am making less than I'm paying my childcare, I love you guys.

But I love my kids more and I'm going to go home and take care of my kids. I'll just, won't see people. So I sent that letter to Medicaid and I said, look, you have 24 hours to either do something about this problem or I'm going to walk and they fixed it. They fixed it. And they put me back up to my regular reimbursement.

And here's the thing that's crazy. But some people will say what they like you or whatever it is. They don't like me. They like what I do for them, which is I actually saved them a ton of money. I have the lowest hospitalization rate in the state for asthma, for which I've never hardly ever been an asthmatic, maybe one in 20 years.

I've never admitted a kid for viral gastroenteritis. I hydrate them in my office over a couple hours. So I am super cheap. I say I'm usually Walmart prices with Nordstroms. For those of you who know Nordstrom's, it's a great department store built on customer service. That's their niche. So essentially I know that Medicaid looks at those numbers and they know that I don't over bill.

I don't do weird stuff. I really take good care of people. And I think that has allowed me to have some ability to push back. And the funny part is I would have been fine if they said, no, we don't care. We're going to let you go. I would just be home with my kids more. And, and I really, it was going to kill me to not have these families.

I've had some of them for two and even three generations. So I was heartbroken and I'm glad it all worked out, but it's when you set your bottom line, it was like, look, I got to cover my childcare. I don't even think that's an unreasonable request. So I'm going to make this decision. And I think they knew that they wouldn't get me back.

So they worked some out.

I'm so glad to hear that they reacted in a positive way for your practice.

I wonder over your years, practicing at Silverdale, how many times have you ever had. To Medicaid for major adjustments like that. Have you, was that the only time? No.

Oh no. I fought with, I probably fought with every insurance company. I have at one point a Regents, which I was one of the posts that I've written, that has done really well.

Regents came and investigated actually me and my dad. They wanted me to account for my dad after he died, they wanted me account for his coding. And I was like, Hey, we code ourselves. You'll have to go dig them up and ask him yourself. And so they came after me for running a flu shot clinic and seeing patients for other reasons.

So people would say we're open one Saturday every year, first Saturday of October, it's a flu shot clinic. But a lot of people don't want to go to the doctor on if they can go on the weekend, let's do it. So a lot of people will come in and say, Hey, can I do my well-child with my flu shot?

Sure. Why not? It's more efficient there. Why do that during the week? And it's just stupidity. So a bunch of people came in asthma checks the chronic, some of the kids who I need to see maybe every three months or every six months said, can I combo this with a flu shot? Sure. No problem. And so then they said, you're not open on Saturdays normally.

So you're making up those visits instead of just doing a flu shot. Only like this year for COVID. We just did drive through flu shots. So nobody had, I think actually one family had a visit for a well-child, but everybody else was drive through. That's an easy billing you just do. Essentially. They thought I was making.

And so that gives me a fraud and I had to do this big investigation and it's fine. I ended up doing fine in the patients. I was real up front with the patients. I explained what happened. I said, I may need you to write a letter, but I just refuse to back down. And of course I write about it now all the time, because I feel like the auditor who came after us was paid to find something wrong.

So the way I look at it, essentially, if I'm not doing something wrong, I'm not going to take a hit for it. And so that was another time I've had multiple Steven Hemsley of United healthcare, but we got into a fight actually. And he was the CEO. He made $66 million that year. And here's, here's that story. I had an eight day old baby who arrested in my office.

So I did a RSV swab, and then they went APNIC and so they had a respiratory arrest and I literally. Couldn't even get to the bag. I gave mouth to mouth essentially called nine 11, got the kid loaded up, got them over to be admitted. And they ended up obviously having RSV that child's probably about 10 now.

And then here's, what's crazy. United health care. During the, um, affordable care act would assign a doctor. If you were on state insurance, they assigned this newborn to a nephrologist, two towns away, two and a half hours drive away. So they wouldn't pay me. They literally, the kid like almost died in my office.

They wouldn't pay me. So we ended up essentially saying, the family says, we're going to pay you something. And I said, well, how about a hundred bucks? Let's just call it even no problem. And so they, they paid and essentially there was no coverage. Like I think United healthcare paid me maybe like 50 bucks.

Then they took it back. Then I talked to this man, his name was Samuel Wilmot. He was a pediatrician originally from New York who was living in Arizona after he retired, because he said he didn't want to be in clinic anymore. And now he was a paper pusher and he said, the human life isn't worth 50. That was literally what he said on the phone.

I'll never forget his name. As long as I live and United healthcare essentially told me I, what I do is I search out the CEOs of the insurers and then I Badger them and their assistance until I got a call. And so ultimately Hemsley sent me a cease and desist letter saying if you charge the family, but we're going to come after you.

And I sent him back a letter saying, go ahead and try you didn't pay me at all. So you're in breach of your contract and the family and I are doing it directly with each other family. I just saw they had to switch to a different, like a group health or Kaiser kind of insurance. The dad works for the school district.

What's funny is when I was picking up the computer for my kids during the pandemic, at the school district building, he and another parent whose child had take care of both came out and they said, we, when we heard it was you, we wanted to come out and see how you are. And the father said, we think about you all the time.

We were so grateful for what you did. And he said, you charged us a measly, a hundred dollars. He goes, I drive by and I want to like stuff money under your door. And I'm like, please don't just give it to your kids. But that's direct care, right? Like I'm not gouging. Anyone he's happy. His child is alive. I'm thrilled.

His child is alive. And he even told me, my wife every year says switch our insurance back so we can go back and see her. And I said, anytime, whenever that's a possibility, you're always welcome back that's care. Wow. So I always fight. I always fight the insurers and I just, I feel like we should, because we're fighting for our patient.


Wow though. I is my response to how much. CEO. It's like, I don't even want to say his name because it's just naming a perpetrator and not the victim. That's disgusting. It's really disgusting.

It is. And I will tell you, the prior auths are a whole nother discussion. I started billing patients for the time it took.

So let's say roughly $35. If you need a prior auth, I know it's not the patient's fault, but my staff, we need to pay my staff. So I, and I can't remember which insurance it was, but the insurance company called or the family called their insurance company. And they said they can't charge you for that. And the patient was telling the insurance company, Dr.

Lodge bill works hard for that money. You don't pay her enough to waste time doing prior authorizations. So we're going to pay it. We don't care what you say. We're happily going to pay it, but we think you suck because you're making her do this. And the insurance company called.

And they gave us a special line to call for quick prior authorizations. So again, it's this funny relationship where they want to dump it on us. And they'll say, it's your doctor's fault. Your doctor coded it wrong, your doctor, this and my patients, most of my patients like, no, she didn't. She did it, whatever it is, you're wrong.

And that makes a difference. It's and I've often said part of direct care is it's me and my patient together on the same side, fighting for them, fighting for better care, fighting for good services. And the thing is no insurance company can get between me and my patient in reality, because we are a team and we'll always be a team.

And we've been a team for some, in some cases, 46 years, because they saw my dad.

When you mentioned the family whose baby you saved, basically the exchange that happened, the a hundred dollars is in Washington state. Is it currently. It's still okay to do something like that. The reason I ask is because when Dr.

Pak was practicing, her numbers were limited because Colorado restricted Medicaid recipients in terms of they could not access direct primary care. So how is it in Washington? And has that

changed? It's interesting. There were no kind of regulations. I would say, maybe even when we, when I first went into practice, it wasn't as tightly regulated.

So what I do is you really can't charge people or do anything if you don't tell them. So transparency is really the part of that. And that's my understanding for Medicaid. They've seen my no-show fees. They know that I charge for what's called non-covered services. The, the important part is you have to let patients know.

And I think you were mentioning on my website, you can see there's this whole list of like, Non-covered services things that insurance covers things that they don't cover. And so I make it, we have a five-page intake form that really is clear with people. Look, if you don't show up and we let you call even five minutes ahead of time, like we're not 24 hours, 48 hours emergencies happen.

So if you call me and you do me the courtesy of saying, I can't make it, I forgot whatever it is. And sometimes people will say I overslept, but I can be there in two hours. Could you fit me in? And I'll still show up that way. And we do if we have space, so nobody's trying to like charge. I don't even like charging it, but it does.

It's an incentive to have, make sure people show up when they make appointments. As long as when they, they become a patient, they are aware that this is what they, as a person are signing up for, then it is allowed. So the state insurance knows I charged a no-show fee and it's very clear in the paperwork.

That is what happens. And as long as you're really clear, like I don't surprise people or try to do something that's underhanded. As long as that's really clear, then it's my understanding. It is okay. Someone may argue on the other side. Oh no. And you're like whatever and whatnot. But again, it's the same thing.

Like the after hours calls, there's no law that says a physician has to be in the office or available 24 7, no human being can do that. And so I charge for after hours calls too. And we used to send them to a service that charged me $40 per call. So I just charged the patient $40 per call. I don't need to make money.

I don't even want to make money off that. I just want my, I want to have time with. And so it's the same thing. It was for Medicaid. It was for every insurance. I charge the same fee for the non-covered services, have an after hours call or a no-show fee. And again, it's very clear in the paperwork. And what's interesting about that United healthcare mess is that they didn't cover anything.

So essentially they refuse to pay it because they said her life was not worthwhile. And what's interesting to me is an insurance company can say a human life isn't worthwhile and a doctor and a patient at that point are really outside of the realm of a contract because the contract wasn't honored on behalf of the insurer there, because they were going to pay the nephrologist.

Who's an adult nephrologist on the eight day old with RSV two and a half hour drive away. So again, I look at that like that's null and void. It doesn't even if it does. Apply because it, they broke their into the bargain. I think what's important to know about the micropractice is at some point maybe over the last 10 years, cause we had to restructure with the affordable care act. It really changed the landscape. I decided that we were actually really not essentially staying our key keeping above water, like a lot of people.

That's why practices had to close. And instead of selling to the hospital or closing it down, I looked at what is the point of insurance? And to me, insurance in an insurance-based practice or fee for service is I get paid by insurance to see a patient, right? That is what I'm paid for. I'm not paid to fill out an FMLA form.

I'm not paid to fill out school physical forms. I'm not paid to fill out all those little medication forms that I'm not paid for. And so I started looking at it from a lawyers kind of perspective. The lawyer gets on the phone with you. And in 50 they charge in 15 minute increments. So the way I looked at it was I'm whatever I can bill for insurance, I will do that people will call and say, and my signature is free.

So a lot of the families fill out their own medication forms. I look at it, which doesn't take long patients know their, what meds they're on. And I sign it signatures totally free. If I have to fill it out, it's 20 bucks. If you want a letter or an FMLA form, it's the amount of time that it takes for me to fill it out.

There's a fee based on that, like a lawyer, because again, none of these things are quotes in. In what your insurance is doing. And so I guess if I was going to say the reason it works out and we've been able to stay afloat is I don't end up having to do a lot of that. A lot of the patients will go ask somebody else to do their forms or they'll take care.

So I don't have all that stuff that I'm dealing with at the end of the day.

How do you have that conversation with a family? Throughout their time with you about just make sure it's a covered service because I know in fee for service, I got that question all the time and I would be directing people to the Medicare app to see if their flu shots covered your team that's covered.

What's interesting is, uh, part of running a micro-practices understanding insurance and who covers what? And I'll just give you an example, like Ghia is a, the government employees. So a lot of the federal employees, we have a lot of their big employer in this area. So a lot of people have the G H a it's like government employees, something.

Anyway, we call it Ghia. So they're famous for essentially, first of all, they don't cover any ER care. So none, no, none of the ER docs are contracted. So when you go to the ER, if you have DHEA insurance, it's a nightmare. They charge you thousands, the patient thousands out of pocket. The second quirk of Gaea is they won't cover procedures.

So if I have a family, like I can think of one, who's got four children and the mom sees home their regular, everyday family, but they may not be able to afford necessarily freezing cryotherapy on the wards. So I already know that. So when I see a word, I look at the family and I'll say, yeah, here's what, here's your choices.

Ghia doesn't cover. This is a thousand dollars. I'll tell them because whatever it is now, whatever I paid for last is what I tell them. But a lot of times we'll get a big bottle. It's a thousand bucks. So say this bottle is a thousand dollars. I could treat 50 or 60 people. We charge, let's say $120 to do the words.

Now with Gaea, you'll have to pay that out of pocket. I said, or you can do this other thing where you get this metaplastic on Amazon for $30. You can get the next care waterproof tape, which is of course what I devised this like way of getting rid of words. And then you just peel it off every day and change it.

And after they shower and I'm like, this is going to cost you essentially 60 bucks, but then you'll be able to treat your other four kids when they get warts, because you got all the supplies. This is going to be 120 personally. I don't really think there's a big difference. And so they'll look at me and go, great.

I'll do this. Sometimes Regents does cover it. So I'll say this is covered and I would still do this second thing. So what it does is it, in my opinion, it puts you in partnership with the family. Like I know the cost of drugs. I know the cost of we have an independent x-ray or radiology place where I am, it's called in health imaging, and then we have the hospital, right?

So the x-rays I looked at bills from both because patients show me their bills, which is fantastic. The hospital bill for an x-ray is $350. It's $40 at the, in health imaging. And the radiologist reads it right there. So I tell people like, this is 40 bucks, this is 350, which one do you want to do? And they look at me and like their mouths are on the floor and I'm like, go over here.

And so again, it's probably just over time and with experience, I know which insurers cover what? And, and so I think I also helped navigate it for the families and I try to keep costs down for them. Again, that's that Nordstrom service, Walmart prices, better medical care. Doesn't have to be expensive. And that's what DPCs really.

Lead the way on that's, in my opinion, what their niche is, they can provide amazing care for very affordable amount. And while my model's a little bit different, it's pretty darn affordable because I don't like to waste money for patients. That's why they come back to be honest. And I want

to go back to the, you have thousands of patients.

And when the typical DPC practice talks about their full panel, 600 to 800 patients for full-time DPC physician, how do you handle 3000 patients? And like you said, you know them because they're people, but how do you handle them in terms of the logistics of your visits? And if you have to do extra care

after hours, So the after hours, I have a, it's technically an unwritten rule, but most of my patients know it, which is there's a couple of emergencies that have to go in right away.

There's a bone sticking out of the child. You could see the bone, it's just gone through the skin. That is a big one. You go in for, if you have a kind of a major head injury and you're not making sense, you go in for that one. And if you can't stop, whatever's bleeding, you probably should go in. So those are my big three.

Now I I'm sure people could split hairs and say, what about this? And what about this? Those are my big three. Everything else can wait until Monday morning, essentially. And if I train patients properly, if I do my job, then they do their job, which is they function. And my patients, I literally have the smartest patients in the country.

Like you wouldn't believe the stuff that they have pulled off without my help. And they even pull it off for their neighbors. Like their neighbor will come over and they'll say, oh, my doctor is closed right now. And they're like, oh, who's your doctor. Oh, Dr. Joshua. Oh, we go there too. Oh, she would tell you to do this.

And this I'm so consistent. They know exactly what I'm gonna tell them to do. And so what's amazing is they, and they always know they can get in. So I don't take walk-ins all day. I, so I know all 3000 and I would say this as a pediatrician, the problems are so much less. You guys have to deal with. Don't get me started, but hypertension, high cholesterol, diabetes cancer.

And again, it's not my, it's not my bag of stuff. I love kids cause it's, uh, I can treat them and they get better. And so for me, the 3000 is probably the same load as you all is like 700. But the other thing is this access piece, which is still having this micro-practice the families have children, right?

Because I take care of their kids. They know I have children minor between seven and 12. So they know that I'm doing like, they don't want to interrupt my time either. They know I will give them my time when I have it. And they know I will see any emergency that walks in my office at any time. And I just had a kid who had a huge, like corneal scratch, actually a minor gouge that I saw in the middle of the day yesterday that wasn't even on my schedule.

And so again, they know I will be there for them. So they don't end up really contacting me much after hours and they know how to handle it. And I think we talk about this in DPC. People will start and think like they got to call you for everything. And then once you get them along the lines of the model, they know how to access you.

They know you're always there. So really that one after hours call that you're going to get from that one patient is actually something really important. And so I think that's how I do it. But again, to be fair to you, all you take care of all ages. I take care of really younger children who don't have the same degree of problems.

So if your one patient has five problems, that's five of my patients. So in all fairness, I think it's pretty good.

Thank you for explaining that because especially for those people who are starting out in wondering, wow, gee, they're just hearing the number. It's really important to hear the dichotomy between. What you're dealing with on an everyday basis in terms of your patient diagnoses and ailments I want to shift the conversation a little bit because you have written so many articles and Kevin MD, and one of the articles really stuck out to me because on the, my DPC story, Instagram feed, someone had made a comment about the DPC is a great model, but if every primary care physician, including internal medicine, pediatrics and family practice went into direct primary care, we would have a massive shortage of physicians taking care of patients in the country.

And so you had written in your article about how there's that the number of residents spots in the country is not adjusting to the population since 1997, as of this interview date, that's still has not changed. And so I wonder in terms of your take on how to address physician shortage, how do you brainstorm a successful solution to physician led care when it comes to direct care or direct primary.

So I think the shortage discussions really interesting because there's, again, so many ways to skin a cat. And the best thing I think is yes, if everyone became a DPC doc, or honestly let's say even the pediatricians became and the geriatricians became like primary, like a micro-practices right?

So for the super old and for the super young, but everybody in between was a DPC doc. What's amazing is think about this just for a second. If you imagine a DPC doc in every community in America, which would be phenomenal. We need fewer ER, doctors, we need fewer surgeons. I'm not general surgeons. I want to be clear on that.

The general surgeons are still going to be busy. And actually they really, I think of general surgeons as primary care because they really handling a lot. So we still need probably the same number of them, but they're not going to be weighed down in a clinic. Seeing patients unnecessarily. Like I just call the surgeon when I know a kid needs an operation and they just put them on the schedule.

So we'd need less neurologists, NES less endocrinologists, less. You just go down the path, dermatology, blah, blah, blah, blah, blah. Every specialty that is overrun right now. Like dry up overnight because by the time you've been in practice long enough, I refer so rarely and people really, it's funny in some of these custody battles with parents, I've had like sisters and brothers of the husband or the wife say that kid had reflux.

Reflux has to be referred to a gastroenterologist pediatric specialists. And I'm like, are you on crack? What do you think? I went to school all this time for, so what's funny is we waste specialist's time. And literally an ER, doc, my clinic runs a little bit like an ER, as far as like, I'm always getting an acute stuff.

If we took, if we were able, if the ear docs were bored, right? Because they just, they weren't that busy. Cause all the DPC docs are handling everything. They're going to come out and open their own DPCs and then think about just all the physicians that would be freed up that are not wasting their time and even think about me.

So if we had DPC in every community, I can change over to being a pediatrician. Instead of seeing every well-child check, I could see stuff that the family docs thought I needed to see weird anemia, weird growth, hormone deficiency. I can handle all that stuff. I do my own bone ages. I do just, my dad was an endocrinologist, so that's a real interest of mine too.

So I read all of that and what's ironic. All those extra doctors would go out potentially with the right incentives into primary care. So I think we will have shifted the balance of our primary care physician shortage. People say you can't handle 3000 patients. I can handle it working part-time and I worked 20 hours a week.

I don't really work that long because I've trained my patients. They've trained me to help themselves. If you need me to make every little decision, I haven't done my job. And so if we did it under that model or the DPC model, I don't think we really meet as many physicians as we think they're there definitely should be.

Don't misunderstand the 1997 budget reconciliation act that kept the residency spots really is a disaster. It was a terrible decision. It hasn't been righted. It's destroying healthcare more than people realize we need more residency spots. We have 10,000 unmatched physicians who need residency spots that could tomorrow be primary care docs.

So again, there's so many log jams in the system, but one of them is this stupidity when it comes to referring to specialists and again, specialists are amazing. We love them. I couldn't do my job without them. I needed a specialist this week when I'm sending a kid down to the ER that I think has Kawasaki's right.

I'm not equipped to do the echocardiogram myself. I'm not equipped to give the IVG. I need a specialist, but that's like once a month, if every person needed a specialist, once a month, that's practicing in the country, let's even go four times. Think of how much cheaper healthcare would be and how much better off America would be.

Yeah. W one of my dearest friends is a vascular surgeon and he would get patients for follow up from the ER visits and he would say, okay, you also have the things that led to your vascular issue, your hypertension, cholesterol your diet.

And he would ask who's your primary. And they're like, I don't have one. And so he would just sit there as a vascular surgeon and do primary care things. Like tell me about your diet. How often do you exercise

yeah. Yeah. And you're asking a specialist who's probably very good at it and kudos to your friend, but it's, it's a, I don't mean it's a waste of resources because I don't want it to sound insulting, but a vascular surgeon, we need one of those to cover a large community.

We don't need to waste their time. And it's, and again, it's not a waste of time for me in my patient, but they have a skill I don't have. So I want them to use that skill to help my patients get better and I will handle what I was trained to do. And that's the mistake. I always wonder, like how can the endocrinologist or the neurologist before months out, and then occasionally I'll get a note from another doctor.

Like they, somehow it gets crossed or they thought I was the primary care doc and it's not. And I'm thinking like the kid's been constipated for two weeks. Like w what do you mean? You saw them for an evaluation? I don't send them until their colon. I just have a kid who's colon is actually prolapsing out of their body, or I guess it's sorry.

Rectum. The rectal prolapse is what they have. And I, I think I know how to treat it, but I do want that person to see a GI doc. That's the only GI referral. I think I've done it in a year but again, that if everybody just sent those kinds of cases, we'd have one or two GI docs for an entire region and we'd be just fine.

So I think the shortage would really be improved if we could develop a better system. When you talk about

training your patients and when you look at the success of your micropractice, I want to ask about the 80 20 rule that 20% of your efforts makes 80% of the change in your day to day operations over time.

Have you found by looking at your practice and looking how you bill and looking how you spend your time, how have you found your 20%.

Yeah. I would say the 20% of resides or sits in conversations with my patients. So it doesn't even matter. Like you could ask any topic. I recently had a patient who asked about the billing and it was something that was like a procedure that just to say it like this, like the dad came in with instead, and it was this diagnosis like warts or something.

We talked about it. We talked about what to do. So I sorta have to build like a lower kind of clinic visit, but I didn't really do the procedure. And so when the mom came in, we generally don't write off anything. We don't change our billing because, but she said, here's the deal doc from now on, ignore my husband, do whatever you want.

Even if I'm not here. So that'll never happen again because they said he wasn't comfortable. So I didn't. So I had to do it this way. She said, listen, from now on, can we just waive this copay? Because now I'm paying twice. And she said, and I'm going to give you full permission from now on. You don't have to ask my husband.

You just know that you and I are square and you do whatever you think might be my kid needs. And so I was like, okay, that sounds good. So again, it's like a, I dunno, $20 copay that it made sense. Her point was reasonable. She wasn't saying, I don't want to pay copay just cause I don't want to pay it. She was saying, does this make sense?

And I'm going to make a change. So it's better for you doc. And I was like, sure, that sounds good. So the reason I tell that story is it doesn't matter if it's billing. It doesn't matter if it's a medical problem. It doesn't matter if it's they want to critique what I'm doing or they say, Hey, I don't like what you said or whatever.

it's the talking with the patient. It's the being honest with them. It's being transparent that I think that investment of time. Pays off in dividends because they really, they have ownership of themselves. Like as the children do too, the children really have strong opinions about their medical care and what needs to be done.

And so what's cute is they will tell me. And so I, again, when the patient tells you, okay, go ahead and do that stitch or whatever it is. I'm like, it hurts. Do you want to have a shot to numb it's one stitch? Or do you want a stitch when they make the decision? The care is better. And especially when there's not necessarily a right decision, let them decide.

So I guess I would say summarizing that the 20% of efforts I put into just talking with my patient and listening to my patient and hearing what they're telling me is probably the best investment I make. Wonderful.

No, I want to go into, your book that you co-authored with. Dr. Rebecca Bernard in Fort Myers, Florida patients at risk. I found it very interesting when I was learning about you in preparation for this interview that you work with Nicki banks, who is a CPNP, there's definitely a lot of chatter when it comes to your book, when it comes to the reality of where the states are in terms of legalizing practices, authority.

Yes. The full practice authority of an app, and more of that is going to happen in the future. As we see 13 coming down the pipes like in California, our law takes effect in 2023, but I want to ask specifically about the conversation and what it looks like in your practice, because you're working with the nurse practitioner

It's not like there's a world war three going on at your clinic. Because clearly you guys have a relationship and clearly it's working. I feel sometimes it's like world war three online or in news articles, even the one that the president of the nurse practitioner association claimed that you had written an article and what you were claiming in the book was.

That you're so money hungry on why you're wanting to limit access to patients. I was just banging my head on the table metaphorically,

because what was it? That's not even true. Everything that you have just

shared is so opposite of that. And I feel that Access to safe quality care is absolute necessity in this country.

So how do you handle day-to-day relationships and day-to-day conversations regarding nurse practitioners and the scope of practice.

Yeah, it's a great question. And it's really fun. It's been fun for me. I think it's been fun for Nikki as well. She found me, so the reason I actually started writing for my local newspaper is that when my dad got sick and died, I wrote a column about how physicians deserve mercy. And during that time, patients were like, this is where I really learned what it means to have a practice.

Like we have patients brought me six weeks worth of meals. They were doing errands for me. They found the funeral music for my dad when I couldn't find sheet music for, uh, what a wonderful world by Louis Armstrong, which is what we played. So people really came through for me in a way I had never experienced before and it's they were hurting.

They had picked my dad out. A lot of them were grandparents. They'd picked my dad out in the seventies to take care of their family. They're still coming. And they supported me as much as they said, I had supported them during kind of the toughest times in their lives. So I wrote an article about that saying like, I understand that physicians deserve mercy.

Look at what my patients have done. I don't know where I'd be without them. And she found that she used to work at children's hospital as a nurse manager while she was finishing her doctorate in nursing. Yeah, in pediatric nursing practice and she didn't even want to work in her hometown. And she said, after reading that she was like, maybe I could work in my hometown.

So she reached out and I was looking for someone to join me. I really didn't. I suppose I was thinking a pediatrician, but she reached out and said, maybe I could just come and shadow you for a bit. And so whenever she got a free few days, we did, we got along really well. We're both this really straight forward people.

So when she talked about that, she'd be maybe interested in working together and I want to be clear. I don't employ her. I don't agree with that. She is not someone I want to really make money off of that. I don't like that idea at all. And obviously I think Sophia Thomas, just to revisit the AANP president, I think she's projecting.

I think for her, it is about money. I don't think there's any question about that when you're going to get on a national stage and behave like she does, and you can see the nation news now segment where her and I were going back and forth in the interview. It's very clear. It was, I almost feel sorry for her because she presented so poorly, but she's clearly motivated by money and there's a lot of.

The state, one of her predecessors got 70 million from United healthcare. Talk about, remember they wouldn't give me a hundred bucks to save the life of a human being, but they'd pay Mary Mundinger, 70 million in stock. So again, there's a lot of money up in those kinds of high level organizations. And so I think Sophia was just projecting.

She doesn't know me. That's fine. A lot of stuff will be written about me. That's not true, but I don't really want to make money off Nikki. My life is fine, but I would love to expand access for patients. And first of all, I did tell her, I'm like halfway through writing a book about nurse practitioners and physician's assistants.

And I don't think it's fair for you to come and work with me and not know again, transparency. It's the same values that you apply to life actually as well and explained it all. I told her the story that if you've read the book about Alexis Ochoa, who I feel like is another daughter to me, I wish I'd known her.

She just sounds like such a fantastic human being. And she died at the hands of an untrained family, nurse practitioner who was working independently in an ER. And I, I knew I was going to like Nikki, because when I told her that story, her first answer to me taught me a lot. She said that nurse practitioners should have never been in that ER alone.

That's irresponsible and she's right. And she said, I would have never, I'm a primary care pediatric nurse practitioner. I'm not a doctor. I'm not a physician. I, she goes by doctor nurse, which I actually, some people do have some issues with the Dr. Moniker. I don't think doctor nurse is confusing. Okay. I think doctor and doctor is confusing, but it's great.

If you ask my patients, they know. Has a doctorate in nursing B no, she's a nurse practitioner. She never says I'm doctor. She says, I'm doctor nurse. And she just likes that you can be both. And she loves to tell the kids that you can do both. And I think that's really neat, but she's really clear about who she is.

And then to go even further, she'd been a nurse for more than 10 years. She like me had worked her way up. She was a certified CNA. Then she got her RN. Then she went back and did her bachelor's and she did her masters. And then she was working in with sick children at children's hospital for many years before she went back.

And she still like, what's interesting, even working with her, she has a really good sense of sick kids, which I always say is the most important thing. She recognizes sick. Bam. I'm not going to say she always knows what to do. She does know she needs help. And so that's what I love about working with her is she is what I think is what's great about medicine and what's great about non-physician practitioners is that they're there to help with the load.

Not saying I have to oversee everything she does. I don't supervise her. We collaborate. We work together. She is in her own business. We share overhead. She has her patients. I have mine. We'll cover for each other if need be. And the thing is it's. I think it's a great relationship. If we have an issue about something, we sit down in the morning and we just talk about it and I'll use an example.

I close twice a year. I have for years to give my staff a break. I love my staff. They're like my own family. So they take a break at 4th of July and a break at Christmas. And I don't think Nikki was ready to take a break. And so I really talked her off the ledge. Go take a break for 4th of July. You do not have to work over 4th of July and go do something fun with your family.

And she goes, it's so weird. We used to have to cover holidays and weekends, and we'll talk about it though. I can only share it on here because we sat down and we had a conversation. So I go to her first. She comes to me first, if we're having any questions or doubts or whatever. And so I think it really works well.

What's funny is as she is working with more schools and continuing to have different, a nurse practitioners shadow her, she gets really frustrated if a nurse practitioner in training doesn't have any nursing experience. And so there's a lot more that I think. We would have in common if we would, her and I have it in common, but on a larger scale, when I really talk with nurse practitioners who have a lot of experience and I say, look, I, my problem is not with the work you're doing.

My problem is people are going to school to be a nurse practitioner with no nursing degree. They are doing these bridge programs. They're training online and they're working in ERs and urgent cares alone. That's my problem. I listen, nobody. And this is the other thing I try to tell physicians, no one is going to replace us, especially DPC docs, especially me.

No one is going to replace me that believe me, I'd love to stop taking new patients. I can't seem to stop the influx of patients. And people will say, you took care of my cousin or my dad or whatever. I'm not going to go anywhere else. And it's okay, I'll take you, but I'm a little bit overwhelmed. And so physicians are always going to be needed, especially in primary care, especially outside the hospital, but you know what?

We aren't able to serve enough patients. And I think he's interesting because she said, she almost feels like she's doing residency right now. And she is, but she is a primary care pediatric nurse practitioner. And she stays within that scope. And again, she goes just as soon as I think about going back to do acute care because this office sees so many things and we were just talking about the fact that over time as we continue to collaborate, I think she's going to get more and more comfortable with those things.

She is, I we've been together two years and she's really just learning by leaps and bounds, but like she said, she never would have gone out on. She said, I, I just, I never want to make a mistake. That's going to harm a patient. And so it's not about me being by myself. Why do I need to be by myself, winging it?

When I could find someone who's willing to work with me, like my dad, he practiced really. He'd been a physician since about the mid 1950s. And he lived in Iraq and he immigrated here and eventually ended up in this town. And what's amazing is right after he died, I'd once in a while say, I don't know what to do.

And one of the dads said to me, it's really hard without parental supervision, isn't it. I'd been doing this for 26 years and I felt uncomfortable without supervision. So I guess I don't understand even what people are fighting about. I think a nurse practitioner, just like a physician who comes out of training and goes, oh, I know everything.

I don't need any help. I'm equal to the doctor. Who's been practicing for 20 years. That's just not a good clinician. I don't care what their background is. That's just not a good clinician. Someone who comes out like Nikki and says, yeah, I sure got a lot to learn about kids. I've only been in it 10, 15 years, but I just never wanna make a mistake.

They're cautious. They're careful. She said, I'd never work in an urgent care. That's the kind of nurse practitioner I want to work with.


It's very different. When you look at somebody who has gone to online school just like Nikki is saying there's so much to learn. I, it, when a person is, saying I am a doctor, that's such a felonious claim when you're, as you stated, Nikki has a doctorate in nurse practitioner practice, it's not a doctor.

And so, yeah, I just, I think that I'm glad that you guys have talks. I think that's the only thing to do. Going back to the divisive year that we had in, in the election in 2020 with the. And all the mask requirements are that not having massive requirements. I feel that just hearing where people are coming from is so important.

And it goes back to how you talked about

supporting people. You may not know this, but one of the studies we talk about in the book is the Burlington randomized trial. And to me, that is what healthcare should be. And that was two family docs in Ontario who were full, their practice was full. They had these two fantastic nurses who worked with them and they started to brainstorm like our nurses could do the diabetes follow-up they could do the, the kind of chronic patients.

And we could just see them every other time, or they were just really strategizing. So they contacted McMasters university and they did a study. They well, they sent the two nurses back for some additional training, about nine months of additional training. And then they did a study looking at how it helped efficiency with patients.

And ultimately with the nurses, seeing the followup, chronic patients, they could handle those patients about 55 to a 66% of the time. So essentially almost like a little more than half to two thirds of the time, 55 to 65% of the time, they could handle the patients with no intervention by the doctor. Now these are chronic pre chosen people, right?

So that was so amazing that they could expand their capacity to take more patients by 2200. So that to me is a like fairytale, beautiful, amazing story of increasing access for patients. And their clinic actually became renowned. And well-known in Ontario as being providing high quality care. And you talk about like how important high quality care is it is, but we have to use our brain.

Like we can't just say, oh, since I worked in McMaster's like every nurse practitioner should just train online for 500 hours and then they should just go work at an urgent care. And again, the majority of nurse practitioners do not feel that way. I really I've been so impressed by the nurse, but not by Sophia Thomas.

I do want to be clear on this. Like I think most nurse practitioners are disappointed in Sophia. Thomas she's really out of touch with her organization. And many people felt like I even represented their organization better than she did because I was saying like, you can find excellent clinicians in all different walks of life.

The. Verifying. Now you ask a doctor, did you go to medical school would like to be licensed so now, but that's not true of nurse practitioners. They could go to online school. They could go to a brick and mortar school. They could, Nikki talks about she didn't get in the first time. So she had to reapply.

It's not a hundred percent acceptance rates where she went at the university of Washington, she reapplied, but she wanted to go to a brick and mortar school. That was just pediatric. She was very specific in what she wanted to do. She pursued that and I give her a lot of credit for knowing that, and she was really clear about what she was doing and intentional about it.

And so the question is, if doctors don't read the book, which is a plug for the book, but no plug for education physicians don't understand the differences like they don't know to ask, are you a clinical nurse specialist, which is a completely different category versus are you a pediatric nurse practitioner who has a certification?

And I'm not saying board certified, I'm saying their certification. She has only trained in work with children. That's a very different thing. Did you go to a brick and mortar school? Did you go to an online school? Did you go to, what were your classes you did? I think we should know those things. And then if, if a doctor gets on one of those Facebook groups and says, I'm looking to hire a nurse practitioner, I can't find a doctor or whatever reason.

And they say went to a brick and mortar school has 10 years of experience as a nurse. Tally ho let's go for it. They will help expand access for patients and they can do it in a beautiful way. It's just, we need regulations. And what's sad is to a certain extent, our book, again, it's gaining steam. It's still really selling quite well.

And it's been interesting that physicians really have enjoyed it. And I think even some nurse practitioners, most of the nurse practitioners that have run, it really have said to me like, wow, I, it was really painted propaganda wise. It was sold as being anti nurse practitioner. And it's not it's pro patient again, what is my entire philosophy?

Pro patient be here to serve the patient and tell them the truth. And that's all I asked for. And I think it's really, it is a felonious as the word I think you use, which I like. It's really almost criminal for someone to walk in the room and say, I'm Dr. Smith. And they're APA that maybe went to get their doctor of medical science.

Cause they can do that. And I think that's inappropriate because I think we should be really clear about who we are. And I'm not saying that I own the title doctor. I don't really care. What I want is for someone to understand the difference in education and background and not because one is better even than the other.

There are PAs that came back from Vietnam. That's what it was started to be the medical Corps corpsman essentially didn't really have a way to work in health care anymore. And so the PA profession was created and there are a number of really experienced PA's that know what they're doing, especially in emergency and kind of more, you know, rural care that's, you know, accidents and injuries, things that they would have seen during the wars.

I think that's a great role, but again, I think we need to be deliberate about what we're doing for patients and not just open up the flood gates and say anybody who can pass the test after 15 months gets to be a nurse practitioner. I think it's sad. It's a sad. And I've told Nikki many times, like you are meaning her.

You are going to have to stand up for your profession because if you don't, your profession's not going to be what it is. You know what it can be.

Yeah. And I think about how doctors who were previously nurse practitioners or PAs, it's hilarious. And I say that in a facetious way that they can have less regulations if they just use their NP and PA degrees versus their MD or Dio degrees.

There is a psychiatric nurse practitioner that we've talked about on our podcast, who led to the death of a well-known kind of YouTube star, Stevie Ryan. And he was wholly inappropriate. He was sleeping with her. And he still has a license. He actually got licensed in my state. Now he can deliver sexual care, dressed a psychiatry with no regulation whatsoever. So you are right about that. The board of medicine, far more carefully regulates what's happening. And I'm not saying that's right.

I'm saying for good and for bad, but the board of nursing is incapable of doing it because they suddenly overnight have all these people, any advanced nurse role and they don't know what to do about it. So it's actually a disaster. Yeah. Fortunately. And

you can definitely Google patients at risk, but we'll also have a link to your book and the podcast on your accompany blog.

Has the book been made into an audio book?

Yes, it's on audible as well. And, and so that's either way it's on Kindle. It's on audible, it's on Amazon and really it was written for patients. So I can't emphasize enough that again, going with my whole value system, which seems to be like a broken record.

When you arm patients with information like I've given up on politicians, they don't frankly care. I've given up on hospitals and corporations. They don't care. Either. People are just widgets. They're not human beings. And so who's going to fix this. I've given up on our medical organizations and there's nothing wrong.

The AMA exists for a reason. I'm really not sure why, but I'm sure there's a reason they exist. And they're, they probably view themselves as pro physician and they probably are underneath it all. It's sometimes hard to see and I'm not involved with the AMA. So I don't want to say either way that I have extra knowledge, but it feels like a lot of our traditional professional medical organizations are afraid to touch this because it is so controversial.

And so how are patients going to know? So essentially I just feel like this is the way to arm them, to explain to them. Not every nurse practitioner or PA is a terrible person or a terrible clinician, but you probably, if you're in an ER and there's no physician on site, which is happening all over the country, you should be told or you should ask, and then you can ask to go somewhere else.

And what that's going to do is that's going to put the patients in the driver's seat. And I think the more patients are in the driver's seat of their own healthcare, the better they're going to feel the better care they're going to get, but patients just need to know what's going on. So that's really the whole point of the book.

It's not about money. It's not about, it's simply about patient information. And I can tell you Amy Ochoa, who is the mother of Alexis Ochoa, doc Ginza. We talk every so often. Actually she's such a wonderful human being. And I just, I can't imagine the loss and that she's enduring my own parents lost two children in accidents.

So I know being a sibling who's lost siblings, but I know my mom I've watched her for years, obviously grieve the loss of her two children and Amy of course now faces that as well. And the thing is she didn't know that her daughter didn't see a physician until after her daughter died. Can you imagine how angry she's a lot kinder than I am, because I would want to wring someone's neck.

I just, I don't think I could ever get over the fact that I was essentially lied to. And even if it wasn't a lie, it was a lie by omission. And to me that's just as bad to do to a patient. Yeah,

absolutely. And that transparency is key and it, I want to segue into. Patient ownership of their healthcare when it, in the light of the pandemic, because you've been featured definitely in your local newspaper with regards to your COVID care.

And I want to highlight that, but I feel that because of the pandemic, people really took more ownership of their health care and what their access to healthcare is than I've ever seen before. And I'm very glad for that because I mean like the frequently on the doctor's pages we see is your doctor or is what are the billboards say?


it's okay to ask. Yeah.

The billboards that say is your doctor a physician, and that it's okay to ask campaign. I had never seen those prior to the pandemic. But it's just, it's so interesting.

The types of conversations I have now with patients where they're actually knowledgeable about the difference between a doctor of medicine, a doctor of osteopathy. People who have a doctorate in something else. So I love that you spoke about your book. I definitely would encourage people just to, to get all the knowledge out there, to look

into it, arm themselves with knowledge because they're safer.

And I do want to say, not only did my patients take ownership for themselves, but they took ownership of me during the pandemic. And I would not have been a safe without my. And when I say that we immediately, I want to say March 9th, 2020, we started temperature checks a full two weeks before the hospital even got on board.

We started masks after I read a tool, go on these new Yorker article, which I think came out like maybe March 20th. So that Monday, which it was somewhere in like March 23rd or whatever, we began masks. And those masks came from all my patients. So hospitals have been asking like sewing guilds to make masks.

So my patients, they're not gonna put the hospital above love me. So they were reaching out, I'm making a few masks for the hospital. Do you need like 50? What do you need? So as soon as we had a hundred masks, which was like a couple of weeks before the CDC did the mass mandate, I think they were still saying like masks don't work.

And I had looked at this article in the new Yorker, so I said, well, let's do it. So as soon as we got a hundred, we started having patients mask. And when we, I don't know if we had the babies, I don't even know what we did to be honest, but everybody started masking them in a garbage can on the way out.

People would put them in there and we'd sanitize them and nobody argued or anything. And then I tried to order, I think in February, I tried to order in 95, just thinking ahead, I have three boxes coming and then of course I didn't get any. And so people rated their storage facilities and I, to tell you the truth, I don't know that I've really even purchased PPE maybe twice to date over the last year.

People brought masks, they brought gloves, they brought gowns, they brought painting, like zip up things from their workplace and they take off the sticker. Cause they're like, Hey, nobody ever wears this size and you're tiny. So just take them because if it saves your life, then I saved the doctor. And what's funny is I would be outside seeing patients in the parking lot.

And I had one guy drive by he's the grandson of my babysitter as a child. She died so many years ago and it was the funniest interaction because he goes, Hey, you, the doctor, I was like, yep. And he goes, he throws a box of N 90 fives at me. These are for you. I'm a grandson. I mean, it was the weirdest interaction it was, but it was so cool.

I was like, wow, that was my babysitter. When I was a little girl. And again, people just kept giving me stuff and I just kept storing it and hanging on to it. And then I started giving it out to the other independent practices. When we had enough, Dennis came and brought stuff like retired dentists, like everybody.

So at the same time, people took care of themselves, but they also took care of me. It was like, they didn't want to lose their doctor because they're like, Nope, we can't lose you because you're going to, we're going to need you. And I stayed open. I never closed. I never I'm in a central business. It was the hospital and me and even some of the adult docs closed.

And I just kept seeing patients in the parking lot. And I saw adults for their acute illness. And again, with transparency, I was like, you do know, I have no training in this whatsoever. And I might not know what I'm doing. And they would say, yeah, that's no problem. Go ahead and see me for my bronchitis. So I was very transparent, but I really expanded the scope because we didn't have.

And again, we, I carried everybody through, no one got COVID in my staff. I went outside and I took the hit. I wore the 90 fives. I'd have the staff stand 10 feet away with a pre-signed prescription. We worked out a lot of different things. And then I know you've probably seen in the newspaper. Yeah. That wardrobe, someone had brought me, people give me stuff all the time.

Like they gave me baby clothes. They gave me like my trunk and my car doesn't didn't use to work. So people would put a garbage bag of clothes. It was just like show up in my car. This has gone. My town is, and people know, I don't really make a lot of money. So I'm just as needing of support. I'm not really plugging for it.

But back then when I was having four kids, yeah. I could use baby clothes. They, someone had brought that wardrobe at some point and we put it next door in the building. And then we, my husband figured out let's trick it out, put a aluminum foil order, a special ultraviolet bulb and put our equipment in there to sterilize it.

And we still use it. I don't really have to go out super often anymore. Now that we have the rapid tests and all these other things, we didn't have all that. And we were literally the blind leading the blind and I just tried to make sure my staff was safe. We had rules and regulations about who could come in.

And I just had my first rapid positive tests two weeks ago of two little kids in my office for the very first time. And that's not the first rapid in my office. That's the first person though, who actually tested positive, who was allowed to walk in my office. Cause we didn't really know. And that's the first person in a year plus who's made it in.

Everybody else, all the positives were in the, yeah. And again, I couldn't have done it without my patients. So I think we forget sometimes how we really have to work. Yeah.

I live in a town of 4,000 people. And on, on next door digest, that was the number one hot thing was who needs masks. Cause our Sowers group is making a bunch and I just love that sense of community and how you've been a part of such a wonderful community for years.

That was just a no brainer when it come, when it came to adding a virus to the mix. And yeah, I definitely would encourage people to check out your blog because your wardrobe is, it's just, it goes back to the similarities between DPC and direct care. It's like nobody who was an administrator needed to approve that wardrobe.

You just

did it correct. Yup. And we just did it and we figured it out in terms of

looking into the flu season and looking into what role will COVID play this upcoming flu season. One of the articles that you wrote about was when your son had asked you early on in the pandemic, mom, what would happen if you didn't make it?

And that brought tears to my eyes because as a mother and as a physician, it really hit home in that we took an oath to take care of people and that wasn't, we took an oath to take care of well people. And so literally it's so wonderful that your community was helping to protect you, but I want to. Just ask that question in this podcast.

How do you, how did you handle that conversation

for folks who have not read that article? It really, that article actually ended up becoming later the title of a Washington post piece, which I now have hanging on my wall because they interviewed my kids for that piece, which was so cool watching my four kids interact with the reporter.

Who's John Cox on zoom was the, one of the coolest experiences really that I've ever seen because they were talking about all sorts of stuff with him. And they were even talking over each other, which was really fun. And that was one of the hardest conversations I think I've had so far. I'm sure there will be many more.

I have a really sensitive now insightful is actually probably a better way to describe my second oldest son. And I snuggled the kids at night. That's kind of my thing. When I'm busy and stuff, I try to spend five minutes with all four of them talking about our day. And he's really my most insightful kid.

And he's the one who asked and he wasn't even 10 yet. You just turned 11. But at that time he just asked what happens if you and daddy die? And my husband works in the office with me. He's the manager. He has an MBA and runs the office. What was hard about it? Wasn't even the question. It was my answer, which again, honest to a fault.

Right? Completely transparent. I'm the worst liar I just said what's going to happen. You're going to go on and you have three siblings and you need to help make sure that the four of you go through your lives together. So I said, I have plans. I know who you're going to live with. And our friends know, and I'm going to do my very best not to die, but I'm not going to promise you that I can't or that I'm not ever going to.

And so I was really honest. Now he started to cry and my second oldest VI of those kids who like sob and they're real dramatic, he's not, he's one of those, like in internal criers, right? So he hides under the blanket and cries and you can't hear him. And when I would come home and say he did a COVID test on someone, or I'm worried that they might have COVID.

I sometimes find him like five minutes later crying over here in the library where I'm sitting and under a blanket. And it was like, he just couldn't even handle thinking about us getting it. And so I'd sit and talk with him every single time, but I did not shield them. And I don't really believe in that because I don't think we should shield children from the truth.

Same with my patients. I treat my patients the same way, like my own kids. They ask me a question, they're going to get an honest answer. And so again, it was a hard conversation, but I feel like. My kids have done well. They haven't been super anxious or depressed. And again, that's not to say that's because of what I mean, that just could be them, although I'm not exactly the fun mom.

I'm the old school, like hard mom. Who's taught them to cook and clean and do more chores during the pandemic. But I think exposing them to the realities of life are really important. Like we're all facing this together. We were all unsure. And I wasn't going to tell him I'm not going to die. I don't think that's, I don't.

I think that's lying to be honest with you. If I told him, oh, I'm not going to die at the time. I didn't know. And even when I knew about hydroxychloroquine early and Emily bringing that up as an example of what he was clinging to, and early on, I'd seen the studies and I made sure that some staff had some pills on hand.

And this was, this is like the February. This was before I knew there was a shortage before there was this big political thing. Again, I just didn't really, I just saw that study the studies and thought, huh? I wonder maybe it's a cheap drug. It's not in shortage. Let's just make sure that my staff just in case has some on hand.

And so again, it's. It was something that my kids heard me talking about. And so they were talking to the reporter and he said, well, at least we have the hydroxy chloroquine. And I said, no, we that's not how that works. That's now we know more. Now we're learning more. It may not work. So again, I was honest with them that I'm feeling my way in the dark.

And the only reason I bring that up is those of us that may have been excited or thought that might work in February long before. Again, this is what can we do? And again, I kept them abreast of the fact like it, no, that actually, it isn't a cure. Isn't an answer necessarily. We need a vaccine. And when the vaccine was coming out, when we went and got our shots, I think it was a real relief for my kids.

And I will tell you, I did. I just gave 450 kids on Thursday. So just a couple days ago, shots. And my son might not that son, he's not old enough yet. He just turned 11. My, my 12 and a half year old was the third person I gave a shot to the first two were patients of mine as well, who happened to be there.

So they wanted to go first, so fine. Anyway, I think, and I talked to my son about it. Even my older son, I said, I'm scared. And I said, what do you think? Do you think I'm making the right decision? And again, it didn't, I wasn't really asking, I'm going to change my decision, but I wanted to know what he thought.

And he said, no, I trust you. This is what you do. You got the shot. I feel like it's safe for me to get the shot. And I do want to do it. I'm scared. Then I said, well, I was scared when I got mine too. I totally get it. I, it was a hard conversation, but I think it's so important with kids, to be honest, and to tell them the good, the bad and the ugly, because if we don't, we're creating problems for them.

Yeah, and

I, I definitely, I admire that passion for transparency because I feel that, especially as a pediatrician, like you talk about your teens and you talk about eye contact with your teens. And if you've been honest with them, when they're three, when they're four, when they're five, when they're 16 and sexually active, it's a different relationship.

And one based on transparency that they already know and are comfortable with. So I think that's wonderful that you have that at home, but I just, I think about those conversations with regards to the uncomfortable things that the life and death facts, I was an adult child when I had a, if you've lost your dad as well, when my dad had his stroke and I had to ask about what would happen if you die in the Philippines, versus if you die here, what would you like me to do with your remains?

And we had to talk about a POLST form and I, as a result, felt so much less guilt. I didn't have any guilt really because of that conversation that we had, and the idea that you're having this super uncomfortable. Gut wrenching conversation with your son. Who's not even an adult. It's like, it's so precious.

And that is what, even when kids don't necessarily remember exactly what happened on that road ship to Seattle, they will remember, this is how mom was as a supporter and as a person who loved me. So I just really loved that. That's, you're so passionate about transparency and I'm so glad. I'm so grateful for your kids to have that as


When, even when my dad was dying, he was in the hospital for five weeks. And the kids were little. I had a four-year-old and a five turning six and an eight year old, and then a kid who turned nine at the time. And when it happened, they asked, is he going to die? And I said, yeah, he probably is going to die looking at all the tubes lines and drains.

I don't think there's any hope he's going to die. And so it was really clear with them in the beginning. And I insisted they all go one time to the ICU and see him. And my second oldest of course is the one who just, he doesn't really want to think about death. And so he only went once or twice. And then when I, when we would go see him, I'd say, you guys treat this.

This is the last time you'll see him. I want you to give him a hug or tell me, love him or whatever it is that you want to say. And I remember the first grade teacher, actually that one of my kids had at the time, my dad took care of her husband as a child. And so she was involved in, she said, my, my daughter, who was about five at the, came up to her and said, yeah, my pop was going to die.

And I just walked in, sat at her desk. And then my son, the, the, the one that was then 10, almost 10, when he was asking about what happens if we die, that kiddo was in second grade at the time. And he was really having a hard time. You'd cry when he'd talk about it. And we would just talk at night and I just let him cry.

He needed to do that. And at the funeral, we have this tradition because of course I've lost siblings. Now I've been at a number I've been at my brother's funeral. And then my dad's. We did. We shoveled all the dirt over the grave. Once we put him in the grave. And so family, we insisted on doing that. And so the funeral home or the burial place knows this about me.

So they backed up the truck with the dirt. And I, and my kids were fighting over the shovel at first. Cause we were going to do this and the poor guy looked like he was gonna pass out. I said, dude, calm down. I got this. So my kids really, we put my dad into the ground and there's a space for my mom and he was cremated.

So it's a little kind of urn. And then the kids shoveled all the dirt and my oldest was like, tampering it down. And he's like, oh, I think at least another shoveler too. And I really made them part of it. And I didn't even think my four year old would understand what was happening. And to be honest, like a week later he said it was Papa in that silver can.

And I said, yeah, he said, well, did they burn him? Yeah. We kind of had to go through the Widy burden for space and why didn't they just dig a bigger hole and all the things a four year old would ask and at the end of that conversation, we're just laying there at night and he says, I'm really glad pop was warm and cozy in his silver can.

And I know exactly where he is and I thought I for who comes up with his stuff, but that's how they see the world. And they think, of course, that's why I'm a pediatrician. If you ask children, you get an answer and you may not always get the answer you want, but they'll tell you the truth and you learn a heck of a lot by listening to what they have to say.


amazing because even my son, who's not yet for. We'll say things from we'll reference things from three weeks ago and we'll have reasoned through the littlest detail. And so it's so true, but it's, I just, I love that. I love that. That is, that fuels your passion for pediatrics as well.

Yeah. I'd be happy in a room full of kids.

And I even used to before COVID, I'd spend my day off volunteering in the school system and I would literally get to go in and I'm telling you, you don't know your patient well enough if you haven't spent time cutting out mother's day cards with them and like gluing hearts on cards and knowing why they picked which card to give to mom and why they designed it that way.

Like you ha you can't know your patient until that time. And, but such a small town. I know you talked about having 4,000 in your town. Anytime I go to do a sports event or, or whatever it is, we were on a track thing for a little while. And one of the kiddos I take care of has a cerebral palsy essentially, and has some difficulty walking.

Her sister would do the track and her, and I would walk the track again, seven year old or 10 year old, disabled walking with the adult. So I could almost keep up with her. And so we were moving at the same pace. And, and what was great is we talked about what she wanted to be someday. We talked about what she thought about the world.

I know this kid, like more than just her doctor and her mom was like watching it. Wasn't it wasn't like I'm off walking around with kids all over town by myself and her mom was maybe sitting or doing something, but we just, both of us wanted to move. So we spent afternoons walking around the track and.

Can you imagine the kids some day saying, oh yeah, of course. I walked the track with my pediatrician, like who doesn't or I have another kid that I raced in the mile one time and she totally obliterated me. I am a disaster when she was like seven, she was running circles around me. And again, they beat their pediatrician in the mile run when they were seven years old.

That's a great relationship.

And when that, they're not going to forget when

they're 14. That's right. And that's really important because at 14 you can't establish it. You can try, but you can't establish the same relationship when it, when a kid's suicidal, they can't talk to someone they can. But it's the conversations that I have with kids I've had, since they were born is really, it's completely different.

It's like another. On that note,

when you are taking care of your patients, you also will do home visits if you have to. So one of the burning questions there was, there've been zooms on this through the Facebook groups on DPC, but what do you have in your bag when you,

well, that's a great question. I should clarify.

I do reverse home visits. So Washington state medical board is, I don't even know what to call them, but they're out of touch essentially. And so it's really not sanctioned for a fee for service practice to go to someone's house. That's considered a boundary violation, which I, it sounds ridiculous for me to say that, but it is a boundary violation.

And my dad was actually brought up on charges for dropping a hat at someone's house because the mom then accused him of misbehaving. He was there for three minutes. He barely stepped in the door as a matter of fact, because he's afraid of dogs and she had dogs. And that was a well-known thing. My dad was totally afraid of dogs.

So anyway, it was eventually cleared and dropped, but it's considered a boundary violation and we need to be careful about that. I think DPC, they can do it a little more cause you guys have a different kind of contract. So it's assumed it's part of the services, right? So I do what I call reverse home visits and I, and it's not super often, but.

They'll come here to my house. Everybody knows where I live in town. And so if I'm around, they know like they'll call me or whatever. And if I'm gone for the day when I'm gone for the day, but if I'm here, I'll say just stop by and I'll see you. And so then we handle it like a regular visit. Sometimes they're shoving their co-pay at me.

I don't even know what their copay is, but they insist on it. And then I just dictate that I was at my house and I saw them for this visit. And this is what I found. So in my doctor bag, that was a little bit of a long entry, but I actually have my father's old school, Eli Lilly doctor bag, the little short one, and I've had it restored.

I sent it to a place to restore and fix where the leather was worn. So I just have a stethoscope. I have a pen, I have a reflex hammer. I have like glucose tablets. I have lots of like bandages and gauze and things like that. I have medication for nausea, so Phenergan and I have the shots and syringes in there have band-aids and I have antibiotic ointment, and I think I even have sutures in there as well.

And some, I don't really, I don't know why, because I don't really have suture equipment, but I do have Steri-Strips Steri-Strips or like lifesaver. And then I have silver sulfur Dene cream, because I use that for everything I'm super old-school on burns and such. And then if I didn't say blood pressure, cuff and a pen and a light that's in my bag.


In addition to what's in your bag, what do you consider your best tool for ear

cleaning? So my best tool for your cleaning has always been those metal curettes. And my dad is so funny. We had one, so he had one in every room. We have six rooms and we, I had this favorite. That was like it, I don't know what was great about it, but it literally had a better loop and we could bend it a little bit so I could get it at the right angle.

And what's funny is I found out one day when my dad was wandering from room to room, that he has a favorite. And it's that one. So that was both of our favorite, like all six rooms. We have six of them. We have one favorite, which is really ridiculous. So after he died, I don't know why, but I started looking on eBay and I found a number of, I think it's size zero is what it is that of the curates.

So I ordered a whole bunch of, so now I have a favorite in every room. So that's my best tool for ear cleaning. And if I can't scoop it out, cause it's hard, then I have this like washer thing that I'll use. What about

for foreign bodies up the

nose? So you don't need any tools for foreign bodies of the nose up the nose.

I just, either I blow in the kid's mouth or the mom just blows in the kid's mouth and out it comes. And if it doesn't come out, then we gotta use tweezers. Essentially I do have one of those little grabber thingies, but, um, honestly I'm not sure it's that I, if I can't get it with a mom blowing or tweezers, it usually needs to be removed some other way.


about for paying districts?

So it's funny that you say that I do like the buzzy bee, there's this thing that came out and it's got ice and it's a buzzy bee, but it really doesn't work in the little kids. So it, and I'm not sure why, I'm sure somebody much smarter than I could tell you why it doesn't really work in the five and under age range.

And so I'll be honest with you. I don't use a pain distractor super often. I just tell them I started talking to them about 15 months because of course I give the shots and I just say, I'm giving you a shot. This is going to hurt for a second done. And I really, even, we have parents restraining their kids, but I just say.

I'm going to give you two shots. This isn't negotiable and it's going to hurt, but it'll be done. And then you get two suckers. So dumdums are probably my best distractor that the dumb soccer's because they're small. And I do want to tell you, I committed to always having sugar suckers when I was five years old and I got my detach, my polio and my MMR still remember it in my dad's original office, which I fish tank in the waiting room, because it was part of that group.

And it was an orange and brown decorated office. It was hideous and they gave me a sugar-free green sucker. You remember? They're like flat and they're like, they're awful. But they were the shape of a circle. And they had the little ring thing. And I remember sitting there looking at the fish and I probably couldn't swear yet, but I probably would swear if I could saying I will never be without regular suckers.

When I'm a doctor some day, I'm going to have regular suckers in my office. And I do to this day. So anyone who complains about that, I'm like, listen, it's a promise. I made to a five-year-old me and I'm sticking by it. And if they get two painful shots, they get two suckers. That's just the way it is. So, so

I totally know what you're talking about with the white sticks, because that's like, you'd suck on them too long at the paper and start breaking up.

And then the ring would fall apart. Yeah.

That's amazing for free. And they were terrible. Like they're disgusting like that. That's not a good thing. A little sugar is worth it. If you get some.

And it can't remember in one article you were talking about how you had some chocolate stashed away for a patient.

So there's definitely, that's a great way to, to be a pain distractor. I think that

totally counts to tell you is, was Piper. And I lost Piper to the flu, which if you've read my stuff, you know, and what's been interesting is I've written about her about four different times. The first was just. I have this patient who died of the flu, who did, who she did not have a flu shot.

Again, her parents had given me full ability to talk about it and they now recommend they really fight on behalf of doing flu shots. And then I just wrote about my own grief in a different post. And most recently, I think even the last two years, I just wrote about how much I miss my friend and a lot of people.

I think that really resonated with them because we would, we would talk like we would have conversations. She would predict what kind of kid I was having because she saw me be pregnant like all these times, four times. And so she's the one who predicted I was going to have a girl when I had a girl. And I remember, I, I don't know.

I just, my dad took care of her mom as a child actually. And the mom and dad remember sitting as teenagers in my dad's office, like when they were, when the mom was having appointments. So it really was a family we're real close with. And I just, my heart broke because she had this expression when I give her shots that just broke my heart.

So for some of the kiddos, I just can't help it. I went and got her chocolate and we would share chocolate, which again is just one of those things that I love about being able to take care of these kids. But again, when you lose a child, I didn't lose. She's not like my, she didn't come from my womb, but she it's pretty darn close.

I had her, I was there when she was born. I was the first person to hold her. I signed her birth certificate and her vest certificate. And the loss is honestly unimaginable. When you've had that kind of relationship. When

you. Look at what happened with Piper. And you look at people who choose to either do a delayed vaccine regimen or choose to not vaccinate.

How do you discuss vaccines with those families who might be hesitant or

anti-vaccine? So that is such a great question because I have never refused to take people who don't vaccinate because I feel like patient access is so important. And I know the American academy of pediatrics has waffled a bit on this again, professional organizations that are a little out of touch, to be honest with the front lines.

I, again, so I'm going to sound like a broken record. I'm sure you can predict my answer. Like my patients. I'm going to be honest. I'm going to say to them, here's the bottom line I recommend. I immunizations are effective, but you are the parent of your child, and I'm going to trust that what's best for your child.

And I'm going to continue to support you in that role. I do have the discussion. I have written my own refusal to vaccinate form because I don't like the professional organizations that have written them. They really make the parents out to be the enemy. And that parent who is not vaccinating is never, there are parents who hate me, probably because of my honesty.

Cause they've told me that and they leave. They're just not a fit for me, but the families who continue to see me and don't vaccinate their children, we have a relationship. We don't agree on that particular aspect of their child's care, but that doesn't mean we can't have a relationship. And just so I do say in every visit, I recommend the immunizations in accordance with the American academy of pediatrics recommendations and they usually have nod their head and say, thanks doc, I know that.

And I appreciate that. You're saying that, and I don't want to vaccinate. And I say, great. So they do sign a form that is really clear. It just says, I acknowledge my doctor recommended shots. I am a declining those at this time, I don't write about their bad parent. They're neglectful. The da. I do discuss that children are, can die of the diseases that these vaccinations prevent against that's part of the counseling or whatever it is.

And again, I still feel strongly that it should be. Yeah, I will feel that way forever because just, I want autonomy to practice. I want a family or a person, a patient, a human being to have autonomy, to make their own decisions. And early on, that's funny what people come up with. A lot of the docs said, oh, I won't take care of people because I'm going to get sued.

And you are putting yourself at risk. If they get a disease, they're going to Sue you. And I'm thinking, I'm going to trust that they will, that we've talked about this. I'm going to trust that they're going to remember our conversations and I'm going to trust that they're making the best. What they think is the best decision for their child.

And I'm going to respect them. And I think with mutual respect, I would hope that they wouldn't Sue me again. I don't want to practice being worried about that, but I feel like it's informed consent either way. And it's the same with a COVID shot, right? I, I gave 450 people shots. There's a lot of doctors online right now on Twitter that are lamp passing me for doing it.

And the thing is every child, all 450 were asked, how old are you? Obviously, 12 and over. And then you're getting a COVID shot. And a lot of them weren't my patients. A lot of them were, but you do you understand? You're getting a COVID shot. So they'd already signed the paperwork. It's all kind of touchless.

Everybody's consented ahead of time. That's another physician in our town. Who's figured out this technological way to do this, but I still wanted verbal contact with each individual child since. You know what you're signing up to do. Yup. I am and I'm doing it and we're going for it. And so I really think informed consent is a huge tenant of what we do.

And I'm not going to be pressured by an insurance company to practice a certain way. I'm not going to be pressured by the state to deliver immunizations when a parent doesn't want them and I'm not going to criminalize that kind of behavior. Again, I probably will have people upset with me, but I feel like every person deserves to make that decision.

Now, one of the things that you said was that the, for particular parents who aren't just not a good fit for you, that is something that I want to highlight because super important. Yeah. Because as a doctor, who's doing a micropractice who has, as we have seen very, a lot of similarities with the DPC model, I feel that empowerment is something that is, it is so different when we look at the empowerment that a DPC or someone like yourself has versus a corporate employed physician.

And one of the articles you wrote was about Dr. Rebecca Lee Crumpler. And it was an amazing tribute because you spoke about that. She was the first black female physician in this country and how. She did not have a headstone is what you were mentioning in this article and how you helped contribute to her headstone being placed.

But the history that came out of that article and just the idea of being empowered as a female of color, and as a physician, I want to ask about how do you talk to others if they're developing that sense of empowerment by branching out into their own practice or their own DPP.

So I tell them just like anything else, they need to honor what their needs are too.

And re Rebecca Crumpler. Really. She was a brilliant woman. I wish I'd known her. She had worked as a nurse and the physicians that were, she was working with actually the white male physicians. That again, you wouldn't necessarily think would be like encouraging the female nurse to go to medical school in like the 18 hundreds.

She must have knocked their socks off. She must be smarter than like anyone else we know. And they were so impressed by her work that they ended up writing her letters of recommendation in a Korean church, encouraging her to go to medical school. And so when I. Thing came across the email where it says we can contribute because she really needs to have a headstone.

I knew it was going to be done in four hours. So I jumped at the chance to enter my credit card number and support this. And it was done in two or three hours. The fundraising was done and I got a letter when they dedicated her headstone to be part of someone, to be part of helping honor someone who essentially paved the way for me to do what I do to me was such an incredible chance.

Like I just feel honored to have been able to give her, I think I donated like a hundred dollars because I wanted other physicians to, I w I didn't want to, I think it was 5,000 they needed. And I was thinking like, I hope other, I'm sure other people will donate, but I want as many as possible to be able to do this.

But even if I'd given $1, I would have felt valuable to support someone who changed my life changed your life, changed life for so many people. And so I really think about a lot of these trailblazers, like her, like Mary Edwards Walker, but like Susan LaFlesche Makati, who was the first indigenous female physician.

Who's really my personal hero who ran a prac. She ran a micropractice and so out of her home. So again, while she had two children and brought them with her on the. Frontier. So again, these women who paved the way, what they did is they made decisions about what they wanted to do in the world and the change they want it to be.

And so I think it's really important when we go out into DPC or micro-practices that we honor who we are like, what's my niche. My niche is that whether you like it or not, your child becomes my child. Some people don't really want that. That's weird for them. It's and again, I don't mean it in a weird way.

I'm going to pop by your house, but in I'm all in, right? So if you come to me, I'm all in like your celebrations or my celebrations, I call you on the day that you're adopting your adoption of your child becomes official. Like I know which days those are. I remember roughly when the kid is born, I know when their birthdays are, I know their favorite candy or their favorite subject, or whatever's unique about them.

And so I'm all in. And if that isn't a fit for you, then you better go somewhere else. So people will say she doesn't offer after hours calls. I just can't call into the nurse and get this care. And I've watched different Facebook conversations say, huh? You know what? Don't not go there because of that, you have no idea, the kind of care that's provided.

And so some people want that after hours care, they want that whole widget thing, like 24 7. That does not mean when they complain about that. I just say, you know what? I'm not the right doctor for you. I, I want to own the health care for your child. And so I can only be here on these times and most things aren't an emergency anyway.

So just work with me on this. And if people don't, if that's not what they want, then. They need to go find someone else. And what's interesting is I do have a kind of a one special rule, which is I don't take people back now. That's not to say I don't take them back. If the kid I was telling you about earlier, who had to switch insurance for financial reasons, like that's totally different or they move away or whatever the reason is, that's not really, uh, not being a fit.

So they're welcome back anytime. And that's a very clear divide, but if you write about online review about, I suck as a doctor and I suck as a human or whatever it is, you know what I don't think I can really do a good job taking care of you. Cause now I'm nervous now I feel really uncomfortable. So you got to find a new doctor.

I'm not really upset with you. Hey, your opinion is your opinion. That's great. And thank you for the feedback. And if I can change something, I'd be happy to change it. But if it's about me as a person. I offer a service and I can only do this. I don't do these other things over here.

I don't do this. I do this. And if this isn't what you want, then I'm never going to make you happy. So I offer a set of services and again, people will leave. Like they, they're not happy about it, whatever it is, I've heard copays. They don't want to pay the copays or they don't want to. If they asked me a question at the well-child and I bill both the well-child and whatever their question was, they don't want to do that.

They don't like that. So then they go somewhere else and I've had even, well, two weeks later, they want to come back and I'm like, I wasn't a fit for you before. I'm definitely not a fit for you now just because you didn't like that. Doctor we'll find a different one. And I never forget. I've had people 10 years later call and want to come back and I edit, just say, look nothing wrong with you, nothing wrong with me.

We're not a fit. And I, it was a pleasure taking care of you. And when I see them in public, I'll talk to the kids. It gets still hugged me. Even after they left the practice, I would never put that on a child or the parent I'll still say hello, and how are you? And maybe I know why they left. Maybe I don't.

For whatever reason, it wasn't working and were not part of medical school. Isn't like you doctor everyone. I'm probably a horrible doctor for some people. And I'm a great doctor for others. And I know that about myself. And again, I want to be clear. This has nothing to do with like race, gender, medical problem.

Like no, if they leave me and fill out a records release form, because they're unhappy with. Hey, I, it's not a good fit. So again, know your niche, know what you do know who you are. And there's one other thing I do like to say, if it's a chore to see that patient, they're not the right patient for you. And I, when I see my list of 20 patients, I don't want to groan about having somebody on my list.

I want to be like, oh, I can't wait to see that kid today. I can't wait to hear how that school project went, or I can't wait to hear how they are at this or that situation. And my practice is probably 95% or more of that. Sometimes I'll be frustrated at kid's really struggling with something that I'm not able to help them with.

Maybe they're depressed or anxious. And I feel like I can't quite breakthrough. And so I'll say, okay, I'm going to try today. Maybe I'm not looking forward to it as much. Cause I really feel like I'm at a loss or I'm not able to help them. That's more what that's about, but it's not dreading seeing the patient cause I don't like them.

So I think that's really important. And

Have you ever had to start a conversation where you brought up that? I don't think that we're a good fit because they were extremely high utilizers or demanding of things that were not necessarily like if they demanded refills.

Without giving you enough time or they demanded care that you were not able to give, how have you, how have those types of conversations?

So usually they'll call into the staff and if they get frustrated, we just say, these are our rules. We can call you. But these are our rules when people are dissatisfied.

Sometimes it's, what's fascinating though, is most people are dissatisfied with the billing, which is something that is a little different for DPC practice. So I've had people who will say one of them was just, I didn't want this double charge and I should be able to ask you, I forget what it was. It was something about, let's say lymphatic, like generalized lymphadnopothy kid either had like maybe inguinal nodes and plus your cervical.

It was enough where it's you got to talk about, or maybe it was even super, super clavicular. I think it was something that, where I really had to talk about. Size and mobility and feeling it. And if it got red and people don't realize how many things we talk about and the moms called and said, I just don't think lymphoma, not these big deal.

I should be able to ask that at a well-child. And I said, you can ask. It's just the way I document and the way we do it is I spent 10, 15 minutes talking to you about the good, bad, and the ugly of lymphadnopothy. It's not that simple. Sometimes it is. And sometimes it's not just depending on the location.

And she just said, I just, I don't want to feel like I can't ask. I said, listen, you can ask. It's just, there will be charged with that. I don't like that. And I said, well, I understand. And there are practices out there that may not do that. Maybe you should find one of those. And once they say, I think I'm going to do that.

Great. We just draft a letter and say, Hey, you've expressed dissatisfaction with the patient physician relationship. We wish you we'll take care of you for 30 more days. And we wish you a wonderful future. And I really do listen. I am well aware that I have personality quirks. I'm probably brutally honest.

Sometimes I say things I probably shouldn't. And sometimes maybe I make a comment that is, I don't want to say inappropriate, but maybe it wasn't the best comment at that moment. And I probably have offended people. I'm human. And if I have, and you feel like it's broken, go find another person I've also cried and spent hours talking to children about their value to me and why I will miss them.

If they commit suicide. I've also yelled at children. Who've attempted suicide because I'm so upset. I can't fathom a world without them. And then I have to stop myself and back up and be like, okay, I'm really sorry. I didn't do the right thing. How can I help you? So sometimes it's just, it's one of those kids actually recently told me that she wouldn't be alive today without that discussion, think of how that makes you feel.

So sometimes I know I'm feeling my way along, but sometimes I think that relationship is really beneficial. And if it's not working for you, then go find somebody else. And that's part of this process. So you can't serve everyone. You can't serve everyone all the time. And I think when we go out into DPC, especially, women's see, this is something that's different about women.

We want to solve everything. We want to fix everything. And there is no one on earth who can fix everything. Nobody, we are just not capable of that. And the moment we recognize that, whether it's because we don't have the knowledge, we don't have the expertise or we just don't have the right personality.

I can't be somebody else. And some, and I remember one lady left. I, I will put kids in time out. I will tell you what, if they are damaging my equipment, they're damaging the door. They're about to jump out my window. I will put them in time out because I don't know what else to do. The parent is sitting there for safety sake.

And so I had somebody I'm trying to remember what happened in eight. They were jumping up and down on the chair and our chairs are springy. So they were jumping pretty high. And I was like, actually worried. And I just said, you need to put your bottom on that chair. And if you can't put your bottom off on that chair, I'm going to take the chair out of the room.

I didn't really put them in timeout. I want to be clear. I wasn't like, but the chair was going to go out of the room and time out because they were not using it safely. And it's, I don't yell at him or anything. It's just the same voice I have. And the mom looked at me and said, you don't know how to talk to children.

And I just said, okay, thanks for sharing that. And she goes, I'm leaving. And I said, I understand there'll be no charge for this visit today. And I just think you need a new doctor who is better at meeting your needs. It's

I'm glad you shared how you handle those situations, because I think it's especially helpful for someone who, and, you know, I definitely would say it's not exclusively a female thing, but I definitely would say that when I see the chatter on the Facebook groups, it's primarily females who are commenting about how uncomfortable it can be to handle high utilizers and DPC who are utilizers, who are making just impossible demands.

And I really appreciate you sharing how you handle it, because I think that the more people hear how other people do it, they might get, become empowered to handle situations differently in the future. And now I want to ask, because you've mentioned that you worked 20 hours a week and you definitely highlighted that you have written articles for Kevin M D your local newspaper.

You've been in the Washington post. Kids have been there. You have written this book with Dr. Rebecca Burnett. How do you manage your time as a mom of four and your practice and. Being able to have the time to, to do self care by writing about all of the things that you write about, because I feel that that's the pie of you time that you are treasuring and you are honoring by doing things like writing articles.

So how do you do it's a work in progress? That's the honest answer. Some days I swear a lot, and that is what gets me through my children have started to swear during the pandemic because they hear me and we're home together. So if you haven't heard a seven-year-old, uh, say the F word, then you can come to my house because it's happened.

And so I would say. Really though self care is probably, I try to spend time with my kids. I exercise every day I wake up in the morning. I started walking during the pandemic with a friend because I couldn't play tennis every day anymore. And so I ended up doing kind of a lot of those things and then writing really is self care for me.

And I think it's really important that we find something we love to do. It's even been helpful. A lot of the articles have been about COVID have been about my conversations with my kids about COVID. This week's article is about the reason I vaccinated my son after losing two of my siblings and death always seems to surprise me.

So for me, it was peace of mind knowing that you don't have to necessarily make the same decision I do. And so it's also like a venting or a working out of problems. The writing and then I've gotten a little better. Now. I used to spend probably a couple of days working out a column, and now most of them, I can just pick a topic and within a couple hours it's done.

And, and like you said, like I used to write more for Kevin MD and write medical articles. I don't have as much time to do that anymore. So what I really focus on is every other week I have a column in the newspaper. I'm probably written, I don't know, a hundred columns by now. And I really concentrate on that.

And if another news agency or media place wants to pick it up, it's totally fine, but I'm not going to be everything to everyone. I need to please myself and I need to continue to educate the community. And so I guess I've even narrowed that a little more. I used to write for anyone who asked and now I'm more just going to do my column, get that done.

The book for me was a labor of love. And I really, I can't emphasize enough how much Alexis's story bothered me. It just, I like I lost sleep over it. It almost feels like another story like Piper, where a kid died, who didn't need to die. And it was at the result of not seeing a physician. And so for me, that is a way of working out my frustration by writing about it.

So I would say pick what you love to do I garden, especially in the summertime now. And I really try to prioritize my kids' activities and stuff. If I, sometimes I won't be in the office. That's why I have the locums person, so I can go to the dance competition or I can go to the soccer game. And I think it's really important if you start to hate any aspect of your.

You're doing it wrong. And what I mean by doing it wrong is I just had this conversation the other day with a parent who's struggling. And I said, listen, if your kids are driving you crazy, whose fault is it? She goes, it's my fault. And I was like, precisely, it's your fault? And I didn't mean that it's like her fault, like in an island.

It's I, and I told her like three weeks ago I had the same conversation with myself. My kids were misbehaving who's fault. Is it? It's my fault. I need to sit on them more. I need to be more consistent with them. I really need to make sure I'm balancing, writing, cleaning, homing, whatever. So again, if you're hating any aspect of your life, whether it's your practice, it's, you know, your home life, your writing, your cleaning, whatever it is, you're not doing it.

You got to figure out what you're doing wrong or what you need to change to make it better. And if it's taking more toys away from your kids to make you happier, Hey, I'm all for it because kids don't need all those toys. Anyway, they're fine with a stick. And I think that's something we really need to remember is we do need to take care of ourselves.

And if my children are not listening to me, I'm not doing what I need to do to make sure they understand I'm the boss and or my husband's the boss or whatever it is. And that's good for kids, right? It's good for us to reevaluate everything we're doing in our lives, why we're doing it and whether or not we enjoy it

on that note.

If others want to reach out to you after this podcast, what's the best way to

reach. So my email, the best way to get ahold of me is niran alagba

That's essentially my name without a hyphen. And then I have my website is neurologic, essentially www dot dot com. And we also have patients at risk. And then my practice is Silverdale pediatrics. My Twitter handle is at Silverdale paeds and my mommy doctor on Facebook. And I usually cross post a lot of my stuff.

And then I write for the Kitsap sun, which is a local USA today, affiliated paper that has been very generous to give me a, an open kind of forum to write anything and everything that I really want to write about. So any of those places, and a lot of people who want to talk to me about various things will even just call my office.

And so that's totally fine. The numbers on the website, and I'm happy to talk to anyone because I really think if we can get more physicians, we can get physicians closer to patients. Again, whether it's private practice, whether it's DPC, whether it's providing care directly to patients, whatever modality it is, the closer we can bring patients and physicians, the better the healthcare system is going to be.

Thank you so much, Dr. Elijah for joining us today.

It's my pleasure. Thanks for having me.

*Transcript generated by AI so please forgive errors.

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