Updated: Apr 29, 2022
Direct Primary Care Doctor, IBCLC
Dr. “Mandy” Dornfeld is a life-long Indiana resident. After completing medical school at Stritch School of Medicine of Loyola Chicago, Dr. Dornfeld, moved to Muncie, Indiana to complete residency training. She and her family chose to settle in Columbus immediately after her residency training where she practiced full-spectrum family medicine for 13 years, caring for patients in the hospital, in the office, and delivering babies.
In 2020 she and her family moved to Whitianga (pronounced FIT-EE-ANG-UH), New Zealand for an ex-pat experience where she worked as a (very rural) GP doctor.
Dr. Dornfeld and her husband, David, have been married for 22 years. They have three kids who all attend BCSC schools.
Dr. Dornfeld has a passion for high-quality care for patients and their families. She is just as happy caring for newborns as she is elderly patients with complex medical and social needs. Mandy has a thriving breastfeeding medicine practice and is a board certified lactation consultant.
Since living in New Zealand, she has a new love for hiking (called tramping in New Zealand), enjoys travel and spending time with family.
She opened Sage Direct Care in August 2021.
Dr. Dornfeld "Pitching" DPC
See Dr. Dornfeld on
House Hunters International
Season 161, Episode 6
Website: Sage Direct Care
Facebook: LINK HERE
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Direct primary care is an innovative alternative path to insurance driven healthcare. Typically a patient pays their doctor, a low monthly membership and in return builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the my DPC story podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model.
I'm your host, Mary consumption, family, physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care. Direct primary care
Direct Primary Care to me is direct access to my patients and knowing my patients well. I'm Dr. Amanda Dornfeld from Sage Direct Care and this is my DPC story.
Mandy Dornfelder is a lifelong Indiana resident after completing medical school at Stritch school of medicine of Loyola, Chicago, Dr. Dorenfeld moved to Muncie, Indiana to complete her residency training. She and her family chose to settle in Columbus immediately after her residency training, where she practiced full spectrum family medicine for 13 years, caring for patients in the hospital, in the office and delivering babies in 2020.
She and her family moved to 50 Anga New Zealand for an ex-pat experience where she worked as a very rural GP doctor, Dr. Dorenfeld and her husband, David have been married for 22 years. They have three kids who all attended BCSC schools. Dr. Dorn killed has a passion for high quality care for patients in their.
She is just as happy caring for newborns as she is elderly patients with complex medical and social needs. Dr. Mandy has a thriving, breastfeeding medicine practice as well, and is a board certified lactation consultant or IB CLC. Since living in New Zealand. She has a new love for hiking called tramping in New Zealand, enjoys, travel and spending time with.
She opened Sage direct care in 2021.
It's so exciting to talk with you because we opened around the same time and you have done so well. And your journey is just so rich. So for people who have not heard of your story before, I hope they listen, very closely. So I want to start with this incredible journey from the United States to another country.
And so you were practicing in Columbus, Indiana, and then you moved to 50 Anga New Zealand. And so for those of you who are HGTV fans Dr. Dorenfeld was actually featured on international health centers, specifically episode for season 1 51. And you can look that up. It's also on her accompanying blog on that note.
One of the things that you had shared was that. You wanted to, you know, work overseas. So can you please tell us about that journey and what led you to ?
Yeah, I have always been kind of a person who's wanted to travel, but I never really had the opportunity in college. I was doing all my pre-med courses and very academically minded and just never made the time for it.
and, just kind of always dreamed of living abroad. but I never thought it was possible as a physician, because of licensing, et cetera. and then, you know, once you kind of start your career and work, build your patient panel and work in a health system, you just can't imagine stopping everything and, changing everything to live abroad.
but when my husband and I made the decision that I would be, Leaving anyway, to start a direct primary care practice that kind of opened up this door to something different. And we said, you know what, if we're going to leave this job anyway and start with a new practice, this would be our golden opportunity to go live abroad.
And I read about other family doctors living in New Zealand, there are other first-world countries and other countries developing countries to where you can work. It turns out, but New Zealand is one of the friends. Probably four American physicians. And I said, you know what? You only live once let's go do this.
So I, for me, it was kind of a natural kind of break before starting my practice. Uh, I, a lot of people thought I had to do that because of a non-compete, but my health system does, I did have a non-compete, but it was, it said I couldn't work for a competing health system. It would have, let me start my practice right away.
So I did not do it so that. It kind of gave us this kind of time to decompress and think about the new practice. but more importantly, I wanted to give my kids the opportunity to live abroad and I thought it would be a new challenge for me to live abroad and learn how to practice medicine in another country.
And living in a very rural area, I think helped me brush up on skills. Thinking outside the box a little bit, we did not have a lot of resources where we live. We were three hours away from a major hospital. We were an hour and a half away from kind of a critical access type hospital. And we were at our practice was really all there was for about an hour and a half around.
So we managed everything we could right there.
It's just incredible. And you know, one of the, one of the quotes that you had said in your interview on the house hunters episode was sometimes you don't make a move based on what makes sense. It's just an example of how, even before you opened your doors to Sage, that you were autonomously choosing to do, you know, this, this journey and to you know, take on all the, all of the adventures that came with that.
So I want to ask there, when you were established in New Zealand, what kind of credentials did you need, if any, to get under your belt before opening? Like, did you have to do any CME? Did you have to learn new formularies? Uh, because of differences in medication, how was the transition over to being a GP?
Yeah. So I joined a group there. So, it's a rather rural practice, but it's a big group because they, they really care for a very large subset of patients. That Yanga is, uh, is a resort community. So during their summers, which are our winters. December January, February, the population grows from about 4,000 to 20,000 and our group, our practice was really the only medical care there.
So we functioned as their acute care, urgent care, chronic care for all of those people. And so I had their support. There were probably six doctors total there and we were on call two at night. We'd go in and see people at nighttime as well if we needed. But there's really, there was really nothing I needed to do other than all of the paperwork.
I mean, they do their due diligence to be sure that you've had the training you're board certified, you know, you've passed your USM Les. So they, they there's a lot of that. Probably it took, I think I decided in June I wanted to go to New Zealand and we were there by January. So it was pretty fast. Overall.
Of course, that was right before the pandemic and which is another story. but with the pandemic, things got a little bit more tricky. And now their borders are opening again, but we arrived in January. A pandemic occurred March. There was a six week, very strict lockdown in New Zealand. And then actually they eliminated COVID completely, which was wonderful.
We lived in a very free life there as far as COVID, but the drawback was, the borders were essentially locked. So if we left, we wouldn't have been able to come back and no one could come see us. And I, I know that probably people, people were feeling the same all over the world, but it was a different experience in some ways than we had originally thought we would have, because we thought we would have visitors pretty much nonstop and family would be coming to see us and things like that.
So that changed things in a lot of ways. And it really. Informed our decisions when we had to make some decisions for our, one of our sons needed a surgery. And instead of going back to the U S for that surgery, we actually paid cash and had it done in New Zealand because COVID was raging and we were so much safer there in New Zealand.
So, there were some interesting experiences that, that way as well,
and, as an American who was overseas, even though you had a position there, you were employed how was that experience paying cash for something like medical care.
Yeah. I mean, I got to see the whole system from both sides, uh, and that could probably be a podcast in itself.
I'm talking about the New Zealand socialized medicine system. Certainly it saves the people there from bankruptcy and things like that. You know, they really do a great job of chronic disease care there. But it's, it's certainly a two tier system. So people do wait quite a long time for specialized care.
Especially if you're from a rural area, which we were so not uncommon to wait three, three or four months to see any specialist or to get an MRI or an ultrasound, things like that. And so a lot of times people will pay. Cash or pay out of pocket to go see, go private is what they call it. And so it creates a two tiered system.
So that was kind of interesting to see how that worked. We were not the, the New Zealand healthcare was not available to us because we weren't there for, we weren't planning to be there for two years and you have to, you have to have a two year visa to qualify for New Zealand public health. And so, that really wasn't even an option for us.
So, yeah, but certainly, uh, healthcare, even when you're paying cash is much less expensive. They're much less expensive. It's
yeah. It's it's so it's so interesting to hear that, that side of the story. And I, I appreciate you sharing a little bit about the health care system. Cause that's that's definitely something that I wanted to know more about and I'm sure the audience did as well.
So, so let me ask you, you know, when it comes to the description of waiting three to four months, it's interesting because when you said that, I think about my community where sometimes it takes longer to, to be seen, you know, for a screening colonoscopy or to see a rheumatologist depending on what type of insurance you have.
So what are some of the things that you thought about when you were, you know, living this system every single day and also having the intentions to move back to the states and open up your own practice.
Yeah. Well, I mean, it's really interesting there. I mean, the government really is in charge of them for the most part cost containment for healthcare.
And so there are things that aren't available there that are available in the us. And you know, I'm not here to speak to what's better or worse. It is, it is what it is. And I was, I'm not critical of their system. I was, I was blessed to work in their system and you kind of just work within it, but, you know, for example, while I was there, they were rolling out colon cancer screening for our DHB.
So before then, no, they had, they did not have a program for colon cancer screening at all. You were not even permitted to do a Hema called screen at all. It wasn't even available and colon cancer screening as it's being rolled out. I think we'll start at age 65. So when. It's just different to breast cancer screening, doesn't start until age 45 there, and it ends at age 65 period.
And it's done every two years with a mammogram. So, cost containment is w for the good of the public health. And it may not be the good of a specific person, but they look at what the least expensive and the best for the public health is. And it's a different perspective when you're looking at someone in front of you and you're frustrated and you want them to be able to get something specific.
So, but we did what we, you know, I, we see a lot of really horrible things, you know, difficult things in America, too. Right. You know, we, we see people go bankrupt here with diabetes and so, you know, I'm not here to speak to what's better or worse, but it's an interesting perspective for sure. But things that I did.
That I specifically worked on while I was there. You know, I took the opportunity to learn phlebotomy had done that since medical school. So, I spent quite a bit of time making sure that I understood how to do that, how to apply leads, EKG leads. I mean, we can read the kgs, but I hadn't applied EKG leads ever.
So, you know, I asked the nurses to help me with that so that when I got my EKG here, I would understand how to do that. So just things like that and the nurses, they were lovely and they were wonderful and helped me a lot with just gaining some skills that I knew I would need.
That's great. And now that you're a solo practitioner in your own clinic, I am sure that you're benefiting from your experience there every single day.
Absolutely. Yeah. Yeah. So I, do you have any kg machine? It was one of my first purchases and so that's nice. And yeah, we have phlebotomy now in my office and I do have an RN, but she's a lot of times doing other things and actually I love drawing blood. I think it's kind of fun. So I'm happy to be able to provide that service in the office.
That's very cool.
Now I want to just go back into your experience in New Zealand, if you're okay with it. You mentioned in the episode how you did take a pay cut. So I'm wondering, you know, if somebody was interested in working overseas, specifically New Zealand, what is the, you know, salary range that someone can expect when they're working overseas in New Zealand?
Yeah. So it's important for family doctors to know a lot of there's a lot of chatter on Facebook and things about working in New Zealand. But family doctors it's a little different as a family doctor working in New Zealand than any other type of doctor working in New Zealand. And that is because family doctors essentially in New Zealand or GPS, which everyone in New Zealand gets a GP.
There is no such thing as like a primary care pediatrician or primary care internal medicine doctor, it's all GPS. And then every other type of doctors considered a specialist in all specialists, essentially work for the government or the DHBs systems. And so if you work for the government you're in a union and your pay is scale by your years of experience, et cetera.
And it's set for you and you get, uh, six weeks of vacation and two weeks of CME paid for, and a lot of benefits. And. Quite frankly, the union and the rules are set up so that your hours are set. As a GP in New Zealand, you don't generally work for the government. There are some rare exceptions to that, but basically you work in private practices and the way you think about it is it's kind of the way I think about it is there are private practices they're privately owned, but they have a government.
The government payer is the only pair. And so it's kind of like an HMO kind of, so they will be then contracted to have a number of wives and they get a number of payments. So a certain amount of payment for number of lives that are enrolled in their practice and you enroll with the GP. And then that is your GP that you go to, you don't go to a different GP.
You're enrolled with that GP. It's kind of like an HMO would be in here in the U S and so when you're working for a private practice, you don't have those government benefits because honestly, they're working on a shoestring. They are trying to see so many patients. And I mean, they don't, they don't have that benefit.
And so I don't blame them, but you can't expect your lifestyle in New Zealand as a GP to be what it might be, if you're any other types of specialists. So. I actually thought I worked pretty hard. We look worked really long days. I took call. It was actually quite difficult for me to get vacation because I lived in a resort community.
And so they needed me to work when it was busy and it's busy in the summer. It's busy at school breaks. And so I think those are things to think about for people going over there. I didn't feel like it was like, oh, this is like, you know, this is nothing. We worked really hard. And, you know, I spent, I spent time at home doing my notes.
I spent at time at home reviewing labs, just like in America. And I was like, oh my gosh, it just follows you everywhere. But I, you know, I enjoyed my time there, but I do think that as a GP in New Zealand or a family doctor, you are experiences a lot different than as a specialist working for the government there.
You know, I didn't get any CME. I didn't, I didn't get paid time off. That was, that was all different. So you make pretty much, I'm trying to think. I think it's around a hundred dollars an hour. So like $400 a session. You, you work in session. So half day is a session in New Zealand and that is only about $75 us per hour.
Gotcha. And how many patients were you expected to see personal.
So I usually saw about four. So if you, so we, in our practice, we had days when just like kind of a typical American practice. We had days when we had scheduled patients and we had days when we kind of did urgent care, like kind of acutes.
And so it's huge. You just like as fast as you could. Right. But scheduled, it was every 15 minutes. Gotcha. Yeah. And you work, you know, four hour sessions
and here's the question. I don't know the answer to where you on an EMR or where you on paper or.
We were on an EMR, but it was quite old. It was, it was old.
It, our situation was, we were so far away, so the courier would come pick up labs at like 10 and 3:00 PM. And then those results would not be in until the next day, like 24 hours later. And you really couldn't get in cloud city faster. That was as fast as you could get them. So if you really were worried about something like GI bleed or something, you had to decide, am I going to send this person over the mountain?
It's a treacherous drive, you know, over the mountain to the ER to get stat labs. And then if you're kind of, if they get there and the labs are normal, you're kind of like, oh gosh, that, that was crummy. I'm sorry. I sent them all the way there. So it's kind of, you really have to use your clinical judgment a lot and you kind of have to think, oh, Send this person on this treacherous job drive hour and a half long drive where you're, they're kind of doing this and over a mountain or, you know, are we going to be able to wait until tomorrow and make sure that everything until we get the labs back?
and one of the other things that you had mentioned in, in socials as well as on on the house hunters interview was that you had always envisioned than opening up your own practice. And so I know that your, your stay in New Zealand had a, a time limit to it. But I want to ask when you had envisioned, you know, opening your own practice, when did that seed start to grow in, in your medical training or medical employment here or was it in New Zealand?
And how did you learn about direct primary care specific.
Yeah. So, I left employed, so I went, I worked only one doc job after residency and went straight to that employed position. I always wanted to do full spectrum family medicine. So I did inpatient, outpatient, paeds, newborn, and obstetrics. Uh, about two years before I resigned um, the hospital went to a straight hospitalist hospitalist model and so we stopped doing adults, but for all that time kind of did everything.
And about maybe five or six years before I resigned My really good friend, Maura MacLaughlin told me, Hey, I quit my job at, my big, hospital system where she had worked and said, I'm opening this practice. And it's a DPC. And I said, it's a what? And she told me about it.
I went out and visited her. So Maura and I went to medical school together. We've always been close friends and I was really happy for her, but I kind of thought she was crazy and I didn't think it would work. But I became more disillusioned with typical employed practice. There were some changes that happened in our healthcare system that took away a lot of what I felt like was my autonomy and changed the way that I practiced.
And I was just unhappy with that. I felt like I couldn't be there for my patients the way that I wanted to be. And I kind of started to think, wait a minute, what is the goal here? Who what's the priority here is the priority patients, because it doesn't seem like the priority is patients anymore. For the people that I'm working for.
And I slowly began to realize I had to change where I worked and it really, I came to realize that DPC was the only model that would work for me. And I probably would have left sooner, but I really had to grieve giving up obstetrics there are DPC doctors who do it, but for a number of reasons, I knew that that just wouldn't work for me.
Here. At this point in my life. And so it just took a little while for me to get there emotionally. So I knew for several years that this was coming in, that I'd be opening up practice. So I went to a DPC summit. My husband came with me. I met people, I took pictures, but I couldn't post on Facebook because I didn't want people to know exactly what I was planning quite yet.
But then when the time came that I was ready to resign we decided then what, here's, what we'll do. We'll, we'll resign and we'll go to New Zealand for a year and a half. And then when we come back, we'll start the practice. And that's exactly what I did. We left January, 2020 came back July, June of 2021 and I opened August 9th, 2021.
So many, so many questions there. So I want to ask first, because you mentioned your husband and one of the things that I love about how centers is they, you know, they say like this house is this much money. This house is, this is this much money. And there was definitely was financial banter between you and your husband in that episode about, you know, which, which Helen were you going to choose.
And so I want to ask when, when your husband and you were discussing about, okay, now, as we're in New Zealand, I'm planning on opening Sage, what was the discussion to plan, especially financially because your husband's a CPA to open. Once you got back to the states so quick.
Yeah. So, you know, I will say opening your own practice is a huge risk.
I mean, going to New Zealand, we, you know, you can say, well, you lost so much money, but we gained so much too. You know, who cares about money? We were able to live. We were able to, for people who wondered, we lived on, well, I made in New Zealand, we didn't use our savings. We were fine. You just live a little bit more modestly.
And we traveled and we did a lot of exciting, fun things. But I think he just kind of reframe, reframe your world a little bit. You don't have Netflix and you don't have, you don't have Amazon, you don't have target, you don't have target and New Zealand. So that just takes a whole bunch of money away, but everything, a little bit different and your priorities change a little bit.
But the other thing that I need to say about a supportive partner is that he was a hundred percent on board with me leaving a really good paying job and opening a DPC from day number one, because he knew how important it was for me to be happy and how important it was for me to be able to take care of patients the way I felt like I needed to take care of them.
And it didn't matter to him. If I was going to be making a third of what I was making or whatever it was, it didn't matter. Because of that. It's not about the money anymore. You know, you can, people make people survive on very little money. It'll work, it'll work out and he knew it would.
So that was never a question in his mind. That that's what we should do. And I should point out that I was always the main breadwinner in our family. Dave was a stay at home dads since my kids were babies. We have three children. He is a CPA and he always worked just tax season. So he always worked part-time during tax season.
So he could be home by two 30 and get the kids from school. January through April until two 30. But I was always the bread winner, but it didn't scare us because we knew that we just felt very confident in that we were making the right decision for us. So, and when,
when you guys though have the discussion that you were going to open Sage, did you guys save up even before you moved to New Zealand to open your doors?
Yeah. So that, yeah, that's a good question. Like how could we come back and start this business? Because I didn't know. I've not done any, I've been blessed that I've not moonlighted. I don't have a side gig So we knew we needed to hit the ground running and get this practice opened as soon as possible.
So we landed, I think like June 9th and I opened August nights, which I think about it's like, that's crazy. But so we did say, we did say quite a bit of money before we left, so that I'd be able to start the practice when we got home and then of course we had to use some of that money to pay for Luke's surgery in New Zealand.
That was unexpected, but you do what you do. So yeah, we but my goal was to get home and get this practice started like really quickly. So when I was in New Zealand, I started posting, I had a, I had a Facebook page for awhile like Dr. Mandy Dorenfeld and I, people kind of follow me and I'd post occasionally and then.
Increasing the posts. And then after I decided on the name of my practice, I changed the Facebook name to Sage direct care and introduced it, that this would be my new practice. And so I already had some followers which worked out really well. And so I kind of started generating chatter, social media, chatter that way.
And so people were interested. And I think that that really helped that I, even though I'd left the community for a year and a half, or essentially almost two years at that point, people kind of still remembered me and my story that I'd been away and came back and that I was coming back. And so I found an office space in July.
It wasn't exactly what I wanted, but we needed to get it, make it happen quickly. From my office space is in a strip mall, which is not what I wanted either, but it's about 1500 square feet. Way bigger than I wanted. But you know, what a lot of things worked out for the best. So we decided my husband also decided to start his own CPA firm.
So we did want space big enough that he could sublease from me because it's just convenient fee in the same space. And the build-out started kind of mid July. I opened August 9th in a back room of that space. Like literally there was construction going everywhere and there was like this little trail you could take.
And there was like a backroom that I kind of had set up and it worked, you know, like the, it looked nice and there, we had it. We had an exam table that I bought used before I went to New Zealand. We had. I had a little desk, I had my computer and things and people were very patient and I look back then, I think they must have thought they were joining this cuckoo practice.
Like, I can't believe that you've been came and saw me there, but they did. And it took about four to six weeks for the build out. And then so I, I now have two exam rooms, an office for my nurse, kind of a phlebotomy station, handicap accessible bathroom, and then a really nice, big open space with like a couch that patients can sit on if they're waiting.
But most people don't wait and then a little coffee station, and then we have a we have like a little break room and then about 500 square feet that I just wasn't sure what I was going to do with it was just there and it's with its own private door and Long story shore, a chiropractor who I've known for 13 years, a really lovely lady was looking to start her own private cash pay business.
And, uh, after being part of a larger practice in town and it just dovetailed really well. She, it was the right size for her needs and I didn't really need the space. And so she did paid for her own out and she's actually opening April 4th. So, and it was, it was definitely a decision, you know, to put someone in that space for one thing, you're sharing your space.
And by doing that, even though I'm not employing her, you are certainly saying something about the people in your space that you endorse them. There's somewhat of an endorsement there, but I know her really, really well and she's you know, I, I definitely. Chose someone that she's very pro you know, very much proponent of Western medicine, vaccines all through COVID she you know, talk to people and posted on Facebook and social media about talk to me about COVID vaccines and why it's important and things like that.
So I felt like it was a really, it was a good match for me.
That's wonderful that you found, you know, such a collaborative environment you're tailoring your practice and your setup to your community. So I really love that.
yeah. So I don't know that she'll be there forever.
I don't know that we'll be here forever. You know, I'd love to buy my own space someday, but we needed to get open quickly. And so we were able to do. And
I love, I love you mentioning that because there's, there's a lot of especially in the people who are, you know, exploring or pre-contemplative, there's a lot of chatter about it's, it's not ready yet.
I'm not ready yet to open. I'm not ready yet. And I mean, you're an example of like, we got to start and it's going to happen August or not. So, so I definitely would say, you know, going back to being in that place of everything is going, to open on this day, whether it, you know, the build-out is perfect or not.
What were did you have any doubts at that time in terms of, you know, like I got to push the date back because I would love to, for you to share this for other people listening, especially if they're, you know, hesitating, even though really, you know, when we look at it, you just need a stethoscope and your medical training to be able to do DPC.
I mean, yes. There's, there's some things like you need malpractice, but did you ever have any, any thoughts that could be helpful for other people to think about if they're in that, that place of , oh, I'm hesitating and they don't necessarily need.
Yeah, I think, I think your points are definitely well taken for sure.
I think you're exactly right. You don't need a whole lot, there are things you do need. However, I mean, like for example, I had a kiddo, you know, I enrolled this lovely family and told them I'll be able to help them with things and, you know, give me a call if something happens. And literally a week after they enrolled one week after I opened.
Their kiddo, you know, needed. He had a laceration on the back of his head and he, I needed a way to close it. And so they, they actually live about 45 minutes away. And, you know, he, he, wasn't a girl's hair. Wasn't long enough to do the little tie trip. I didn't have, I had suture, but it's been so hard to get lied to Kate.
I didn't have lighter cane. And I'm like, oh my gosh, duh. And so she'd sent me a picture, so I kind of had an idea. And so I but I didn't have any, I didn't have anything. And so, this is where, I mean, you know, just using resources, there is a private practice, PT practice in town. That's not a part of the big health system.
And I just called one of the pediatricians up. I said, look, would you let me borrow a Dermabond? And I'll pay you back for your turbo bond. And she was very kind and what may do that? And so I was able to meet this family at the office and it was the type of lack that, you know, staples might've been ideal, but Dermabond was fine.
It was like a three-year-old. It was fine and it saves this family a lot of money, you know? And they were happy as could be. So I think there's things like that that definitely will come up. And it's like, oh gosh, I'm going to need that. You know? And now I've been open for seven months and someone just, you know, made an appointment to have me take staples out of a laceration of like, I don't have a staple remover, so I had to get on and, you know, have the state board set, but at least I had some morning, so I could get it here within 24 hours.
And there's things like that that do come up. But usually, you know, I mean, it would have been okay if I told that patient, I'm sorry, you're going to have to go to urgent care. But I wanted to try to do what I could for them, you know, so yeah, I think kind of using your resources when.
Yeah, no, I'm, I, I though I feel those words to my bones because, you know, I think about what Dr.
John Jacobson said, he doesn't necessarily practice what he preaches. And so I think back on my own journey, being a mobile practice starting out, you know, I I've definitely done procedures in people's homes, but when I'm like, oh my gosh, I don't like the feeling of not having something.
So I really, you know, tried to pare down what, what I needed, but I mean, even, even opening, I had purchased things from anda because I was like, I don't want to be caught without things like suture and things like Dermabond. So I really appreciate you sharing that experience with that family and what you were able to do because of how you were resourceful.
Yeah. And so I just think, you know, families understand too, and you kind of make the best of it, but But we won't always have everything we need that, you know, I didn't always in fee for service either. So I think you have to remember that. And I think that families really are appreciative of what we do for them.
And that, uh, that brings up another point. You know, I decided to go ahead and have texting service and I use spruce and you know, I find that patients really, really appreciate that. And I, I kind of decide when to write them back and when not try them back, you know, that's, but I have patients text me all the time and they know that that's kind of okay, because I feel like that's kind of when it works for their life.
And so I know we, there's a lot of discussion on Facebook about, you know, when should patients text you or are they allowed to text you in. Who am I to say when there, you know, I don't know when they're awake or when the, you know, maybe they just got home from work. And so I try to think of it from their perspective too, you know, like they just thought of it.
I can't, you know, they, that's not their fault now I'll make the decision about when it's appropriate Trice and bath. But I think that they really appreciate having that as an option. So for me in my practice, that's worked out.
That's great. And, with having three kids with, having your practice be, more than half full by the time of this interview you know, it's, it's really great that you talk about boundaries because boundaries are definitely something that sometimes we don't necessarily know what we want those boundaries to be until we experience something where we're like, Ooh, don't want to do that again.
So, and then, you know, you and I are very similar in, in not only opening date, but also technology. You and I are both on spruce and servo. So how do you in terms of using the platform with servo, as well as spruce, how do you combine those two to work well for your patients?
Well, I probably have not as technologically.
Uh, smart as you are, because I know that you're really, really know a lot about the servo and all of the amazing things it can do. But what I just literally will open spruce on my desktop and I will, if there's a conversation that needs to be documented into servo, I will copy and paste it into an encounter note and I'll just label it, text conversation.
And then if I have made a plan as a result of that text conversation, I'll literally straight assessment and plan starting, blah, blah, blah. And then that's it. But it's actually really easy to just copy and paste in your desk on your desktop. So I don't, I do not copy and paste every single text conversation most are just not significant.
But you know, anything. Significant enough that we're actually discussing something medical, you know, I will,
I really love it. And I did choose to hire, I got to about a hundred patients and I really was feeling I needed some help. I don't know how people do it with a micro practice or a practice without any help, but I was feeling like I needed some help. And so, I chose to hire an RN and it was a fantastic decision.
I always knew I wanted an RN. I wanted someone who had that extra medical knowledge and was licensed. I am an only provider practice, and so if I'm not here that day, I can call her and say, look, someone's coming in. I want you to do these vitals and tell me what they are, or I want you to, you know, they need this.
they need a recessive and shot. I know, you know, I already, I already decided and because I'm, if I'm not in the building, it's okay. You know? And so I feel like she also has 20 years of pediatrics experience. So she is really great at giving advice and triaging if I'm seeing patients and she's, you know, Manning the phone, but it's so wonderful with spruce that we both get the text messages.
I mean, I think that's really, great. We both really like spruce, so it's been, it's been good. And so my RN also is basically my practice manager too. She kind of does like social media practice management and then kind of RN stuff.
talking about your RN in terms of in terms of employment, does, does she work as a W2?
Is she attending.
What is she? So my husband's a CPA. So she set this up. She's a 10 99, I believe.
Yeah. Yeah. So I love that you mentioned that as well, because you know, people think of a 10 99 is, you know, like gig work for tech things commonly, but at 10 99, for somebody who is an RN is definitely a way to start out.
If you are not sure if a person's going to be a good fit or if you're financially just starting out and don't necessarily have the, the plans for a full W2. So I love that. And how did you end up finding your.
You know, I actually had about six or seven people reach out to me after I opened and say, if you need someone I'd really like to interview for the job.
So people just, who kind of knew of me in the community or knew me, or have worked with me. And she was one of them. So I didn't know her well, but she's kind of a friend of a friend who I knew of and she, she's kind of just perfect for the job. So, so yeah, I was very lucky because right now it's really kind of hard to find people to work in the office.
But I do think, you know, finding an ma might've been more difficult for me, but I just for me it felt like an RN was a better fit for the job description. So yeah, worked out really well.
Perfect. Now I want to focus on your growth because like I just mentioned, you know, you're over halfway full.
Your goal to my knowledge is 350 patients, which is amazing because I just learned about a doctor in Northern California who works for corporate system, taking care of 4,000 patients. I want to highlight the wins that you've had in your DPC, specifically with growth. So by six months you had onboarded over 200 patients ages, zero to 85, and you had welcomed your, your RN to your practice.
So I want to ask about, you know, going back to August, you were opening, you had some chatter on Facebook, like you mentioned, how were the,
opening days in your practice in terms of how many people were pre enrolled or did you even have pre enrollment and how was getting patients in for.
Being scheduled to physically being seen in your practice.
Yeah. It's kind of actually hard to remember now, but I think I had about 30 pre enrolled because there were a lot of people who said, oh yes, yes, I want to sign up. But then they didn't really understand what DPC was. Right. So you need to explain, I mean, it's still a relatively new model here in this part of the country.
There is another DPC doctor here in town. But again, I don't feel like it's still a well-known model here at all. And so like people say people either get it or they don't and the ones who get it and they're like, oh, no problem. Great. And the ones who don't are like, what we literally had someone make Megan, my nurse called someone back.
We were making a home visit together and I was driving and she, she called someone back and I heard her on the phone and she was talking to them and explaining it. And she said, And she said, well, yeah, here's the price. And it's monthly and lady sit in the way we could hear her whisper to her husband.
That's crazy. You know, clearly she did it, wasn't for her and that's fine. But so there were quite a few people who at first thought they might be interested, but then just the model, wasn't a good fit for them. So I think I had 32 people enrolled before I opened my doors and my growth has been, uh, just about a tiny bit over an average of over one person, a day enrollment since I opened and getting them in.
Oh, I remember those first couple of days. I think I may be just scheduled maybe even for a day or something. And I just felt like. I was going to drop dead at the end of the day. There's just so much, you know, learning, learning a new EMR is definitely challenging. And then you're doing, you're the only one doing, putting the specialists in loading the loading, the radiology plays, you know, faxing to get to, how do I fax it?
We'll wait a minute. I want to add a cover sheet. So all those little things you just don't think about, you know, you're doing all of the administrative tasks. You need to get records. You know, that fax didn't go through. I need to figure out why. And so, you know, it just took a lot of time to become efficient.
But since then I have really done, essentially almost no advertising. I did participate in the community. Has the newspaper has like a contest for best doctor, you know, best, every best of everything. And it. $350 to participate in that if you put your picture, I think in it. And so I did that and I also did a ribbon cutting with the chamber of commerce and they, I think you pay $350 for that because there is an ad of the ribbon cutting, and those are the only two paid advertising.
That's incredible. And I, in terms of, you know, adding one patient a day, I definitely would say, you know, that that is hard work. So congratulations on that. But when you were seeing this amazing growth, what were people saying as their lead source? What were people saying? Like, oh, I heard about it from so-and-so other person who's already joined your practice, or how did your practice grow?
So quickly without, you know, investing so much in advertising?
Yeah. I mean, word of mouth is huge for sure. I mean, basically that is it. That's, that's all it is for me is word of mouth. But I think there's some, there's like a mommy Facebook group and I'm in it, but mostly just to kind of be stalking, I try not to comment and I do see that My lovely patients are quick to recommend me, which has been very kind of them.
I, I think it really helped that I was well-known in the community before and probably had a patient panel of around 2000 patients. And I also delivered babies before. So they were patients who would kind of come and go as obstetric patients as well. I have a few families that are health share type families, and it seems that some of them are kind of in the homeschool community health share, and they all kind of, that kind of goes together for whatever reason.
And it seems like they will recommend to each other. So I think that, you know, if, if they're happy, I guess they tell, tell other people. And that's what we want to do is keep people happy.
Amazing. And because they love you and your practice so that
it is a different model. So we just, we really want to treat people well.
And I think it's just high, high personalization. And I think that most DPC doctors would say the same. And I will say also, I think my nurse, Megan has really been a huge part of my success. I mean, she gets it, she gets DPC. She gets what Sage direct cares about. She gets our values and she is an extension of me and our brand.
And so when I'm not able to reach out to a patient, I see her doing that on text or, you know, by phone calls and doing what I would want to be doing if I had the time and patients adore her and she is just an extension of the brand and she really takes good care of people.
I love that they extension of the brand, because at the end of the day, you're working as a cohesive clinic and you are the lead person.
You are the person who's on the website. When people see your, your photo, you are the doctor. And so it's, it's incredibly important to have anybody who's working with, you really understand the model. It makes a difference because when you talk about the word of mouth, any, any interaction with your clinic, whether it be on social media, whether it be talking with somebody on the phone or virtual assistant you know, that you can, you can really benefit from somebody, like you said, who really understands what direct primary care is and who is you know, a cheerleader for the movement.
Yeah. Yeah. So I think that, you know, having the right person working with you is really a huge part of DPC. I think you could also have the wrong person and it would be, you know, I remember when I worked in employed practice, There was someone who worked at our front desk who was super unhappy and not nice.
And you think, okay, this is, this is someone who greets people when they, the first person who greets people when they come in and they're not a nice person, they don't, they aren't kind. So that is kind of, it's a lesson, you know, you need to have the very best kindest person right there. And so, you know, you just, you ha you have it.
Customer services is a big part of what we do.
Yes. And at the end of the day, like many people have said, we are a business. This is a business model, but we are choosing to you know, run our, our desire to care for others under this business model. And so it matters when we're taking care of patients and it matters when we're taking care of patients when finances are involved, especially with.
I want to ask about your pricing because I actually clipped your, I took a screenshot of your pricing and put it on your accompanying blogs so people can see it as well as on your website, but I loved how your, you came up with your pricing. And so I want to go back to the fact that, you know, you have, uh, an excellent resource when it comes to finances and financial planning.
How did you develop your price point? And have you changed it over time?
Yeah, so my pricing is kind of unusual for DPC. I mean, anyone listening knows typically DPC is age, tier base. Mine, I felt like the complexity of the patient really isn't dependent on the age and pediatricians who do DPC. I'm sure will tell you that too.
And I feel that on. Pride myself in really taking good care of children too. It's spending a lot of time with kids and sometimes kids are very complex. I have some medically complex children in my practice and I enjoy that. And even if they're not medically complex, the parents can share how to take a lot of time.
So I don't really know that we can say, well, kids are, kids are inexpensive and older. People are not are, are expensive. I feel like a patient is. On the other hand, I did, I wanted to do something for larger families to kind of give them a break because I just feel like those families, you know, that's really, that would be hard for them to access DPC care if they had to burden, you know, if they were burdened with that full cost for when they have you know, more than three or four kids.
So I also wanted to keep it simple cause I was imagining trying to remember, well, when they change age tiers, then you kind of have this awkward conversation and it just seemed difficult to me. So I just wanted to keep it simple. So the first family members, a hundred dollars, the second is, uh, 75. The third is 50.
The fourth is 25 and I tap it 250 per family. Period. The enrollment fee is 75 for the first sailing member in 75, the second family member. And it's capped at 150 per family period. So part of it is just, my simplicity is just, it's too complex. If it's anything else, part of it is also, I think they need to understand that part of is a buy-in to this model and they need to understand what their, what I want people who are committed to a long-term relationship and understanding, you know, that they're really getting a high level of care.
Your patient number has definitely shown that people understand and value the model in your community. So I think that's wonderful. Let me ask you there just, in terms of your community, because you were, working in a fee for service model for so long and then opened up your DPC after you returned from New Zealand, can you share a little bit about your community in terms of, you know, who are, who are the typical people that join your practice?
What's the average income in your area that people are able to buy into this model and afford this
model? Yeah. So Columbus is community of. Columbus proper is about 45,000 larger Columbus is 65,000. It's a small city, but there's quite a bit of rule around it. Farming community around it. We are the worldwide headquarters of Cummins engine company um, which is a large diesel engine company.
It's a fortune 500 company. So there are quite a bit of engineers here. So my, my practice at this point, I do have quite a few, uh, patients with traditional insurance, Cummins patients, et cetera. I opted out of Medicare from the very first day. And so I have Probably about 10% of my patients are Medicare patients.
I have probably about 10% of my patients have no insurance whatsoever. Not even health shared nothing. And you know, I can encourage them, but at least we're getting, I mean, they're getting some care and these are people with really significant chronic diseases. I saw a gentleman in my practice this week with no insurance whatsoever.
He's been using his old C-PAP, which is great for sleep apnea, but his blood pressure when he walked in was 180 over one 20. And I was really glad to be able to take care of him a hundred dollars a month is a great deal. And so, but basically his employer had said you can't come back to work until, you know, you get some of these things taken care of because it's unsafe.
So, so I think honestly that's a, that's a good deal. And then I actually have a handful of patients who have Medicaid. I, we do have a status in Indiana of an ordering prescribing, referring status for Medicaid, so I can order prescribed, refer and they have chosen to come here for a number of reasons.
I think being a little bit set up with the system, I think with the pandemic, the pediatricians in our community kind of change access and no, no fault of their own but you know, change the way that patients can access the and get appointments. So it made it quite difficult at times as a working parent to be able to get in, you know, for appointments that work with their schedule.
I have one kiddo who's significantly medically complex and has Medicaid because of that. Mom felt like it was just, they weren't getting the time they needed, you know, in a 15 minute appointment. So, you know, I can, I can help them out. But I think, and then a lot of families, I have several families with health shares and you know, and a lot of big families with health shares.
So it's a good deal. If you have six kids, eight kids and you're paying $250 a month for primary care.
Absolutely. You know, I can imagine what, what a family of six would have to face, had they not had access to your practice in terms of, avoidance to go to the doctor as a cost, as well as, you know, just co-pays that might add up for every well-child visit or every time somebody gets sick and then delays in care.
Uh, definitely add up. If you have to go to the urgent carousel, it's just incredible. No, let me ask in terms of, because you're in your first year, this is based off of some dialogue that I've seen with regards to overwhelm when it comes to growth of the practice, when it comes to the types of patients that you're taking care of, when it comes to boundaries, any and all of the above, when it comes to, you know, feeling the sense of overwhelm as a DPC physician and owner.
So I want to ask in terms of your time in DPC, have you experienced overwhelm and how did that overwhelm look to you and how did you get through those times
yeah. I definitely feel a little overwhelmed at times. And I considered pausing new enrollments, but I really don't think I should, because I think it's hard to get that momentum going again, because then it's like the word gets out that, uh, Dr.
Dorenfeld is not taking new patients. So I think that. You know, as long as we can kind of just kind of keep on keeping on I'm going to, I'd like to just get full and then have a waiting list. And I actually think things will settle down quite a bit because I don't know what other DPC doctors have found, but I find when onboarding a new patient it seems like it takes out quite a few, maybe a few appointments before they're kind of settled in maybe there's some acute issues we need to deal with, or maybe some chronic issues that were not taken care of for a long time.
And so there's just a lot of attention that we need to you know, give to that person. And so it's just, it's just a lot. So I'm hopeful that, and that's kind of what I keep telling myself that once I get to kind of a sustainable point where we aren't growing that everyone will kind of be settled in and.
I can catch my breath a little bit. So for sure, that has crossed my mind. I could not do it without a nurse, you know, kind of, uh, a person to bounce ideas off of. So for me, that was huge. That. It's also a gift to myself because clearly I pay her and you know, I could make more, I guess, without her, but for me that was, that was definitely worth every penny she's, she's really, really helpful to me.
And and then my husband's you know, he doesn't work for us per se, but he is in the same building as he subleases, but he kind of manages kind of the behind the scenes is like the like if a credit card doesn't go through, then he'll kind of be the person who calls the patient and says, oh, we noticed your credit card.
Didn't go through, do we need to change the credit card or something? So it's kind of nice that like, as the clinical person, I don't have to do that because I don't want to do that really. And so it's really great that he's able to do that kind of take on that.
Gotcha. And how about in terms of your schedule?
Like you mentioned, how, like you'll ask for you know, records to be sent to you. Do you have time in your schedule that you've blocked for like administrative tasks or doing the financials? How does your schedule work?
Yeah, so I don't schedule patients on Thursdays. I will see people acutely. Like if, you know, they call in and they're sick or whatever, it's like this past Thursday, I saw two people.
But you know, so that'll be my day to do, do things at home, but I'll also, you know, come in and do things around the office or do administrative things and or Megan and I only talk about, you know, upcoming social media posts, or we have like a little newsletter we do every three months. We talk about that.
So, kind of that's kind of my day. So things like that, but I would say honestly, It's still, I still worked so much with when I was in fee for service, you know, and on-call all the time and it's just so many notes and messages and it's just, my life is so much fuller now. Really? It's just.
I love it. And one of the things that I loved, reading about on your website and, I'd love to have the audience hear more about is you are also an IB CLC.
And so can you please share about the breastfeeding medicine arm of your practice?
Yeah. So, I do have, so Sage is Sage direct care and breastfeeding medicine. And I was doing breastfeeding medicine. I've actually been an IVC for 10 years. So I've been doing breastfeeding medicine for about 10 years.
And I'm a member of the academy of breastfeeding medicine. And in private practice, I started that in putting that into my practice and to the point where I was seeing consults from outside the healthcare system, people were coming to see me for breastfeeding medicine consults. And I think honestly it probably frustrated the healthcare system somewhat because I was, did not have enough time for my own patients.
But it was something I loved and I felt like is a really important, there's a need for it. So I have two exam rooms and one reason is that one is set up for breastfeeding medicine. I can see other people there. I could, you know, so it's nice to have a second room as an option. You know, you don't in DPC, you don't have, you don't really need more than one, but it is nice, you know, to have a second room, if like during the height of COVID here, you know, someone came in accidentally, you had COVID, we could kind of like close the room off and then have the other room.
But so I use the other one for breastfeeding medicine generally, and it's so nice. I have a recliner and I have the baby scale and everything I need in there. And so for that side, if you're a member of the practice I figure you get everything I have. So if you're a member of the practice and you need breastfeeding medicine help or breastfeeding, There's no extra charge because I kind of figure I can't.
How can I delineate that? Wait a minute, while I'm helping you with your baby and oh, all of a sudden, now I have to charge you. It's just, I can't do that. So, but is you come to me and you're not, and then we have our practice. That's the one time I'll see non-members and so it's kind of an, a cart fee.
And I, uh, I block an hour and a half for a full consultation with the mom and the baby. And, you know, we can address things like core gain or pain a tongue tie you know, all kinds of things. And generally I do a full assessment of mom and baby walks, a baby nurse do pre. Wait and then kind of develop a whole feeding plan and and what I tell the mom, and then I, I do invite them to spruce and I tell the long, you know, includes two weeks of up.
And I'm sure if she called me later, I'd probably answer your questions too. But generally it seems like that works out. So I don't know if that's the right answer or not for that, but it seems to be working. So I have not really promoted that because honestly I've been so busy with, with my DPC patients.
So the patients I've seen have just kind of come because they've heard. So I do give them a. Servo allows you to print out a receipt with like the CPT code and the ICD nine code and everything. And I do give them that they want to try to submit that for their, to their insurance. Obviously on the DPC side, we don't do that.
But for that side I do. And I do use lactation codes and some patients have been reimbursed, but I warn them. I can't guarantee that patients can also use their HSA if they want. So that's kind of how that works. And at some point I probably will want to promote that a little bit more. I have, I'm probably see, I don't know, three a month right now.
But right now it's just three months fine. But at some point I'll probably grow that.
And when you talk about growing that some more in your future, and going back to the, the goal of reaching three 50 for your practice, I want to ask, how did you come up with that goal as how did you come up with that number as your goal?
Honestly, I kind of looked at well, I knew I wanted to have the breastfeeding medicine practice as well, and I wanted to be able to have time to be able to do breastfeeding medicine. So that was one reason why it's not like four 50. And then I also kind of looked at what I expect my per member per month to be.
And I really wasn't sure what it would be. You know, you don't really know like what your average will be. But my average seems to be about $75 per member per month. And then you kind of just look at your expenses and start subtracting them out. And, you know, you know, my nurse is my most expensive expense.
People always are. And then, you know, your rent and everything else. And then just look at, am I going to be able to, what do I need my income to be? And that's kind of how I came up with that number. And so, I mean, it could change. It was it's literally, it was a shot in the dark. I mean, I didn't know when I was in New Zealand kind of coming up with this.
I honestly, there were so many days I just thought, well, anyway, even com well, anyone sign up? I don't know. I mean, I didn't know.
absolutely love you sharing that because it is, a leap of faith that we all take. But that is definitely grounded in the idea that we value autonomy. We value quality patient care.
And so I love that you have the time to, you know, to, to run your practice the way you wish to run it. And your practice is thriving. So I want to ask in closing, when you look back on your experience in fee for service, your experience in New Zealand, your experience so far in your DPC, why should people look into this?
think this model, oh, I don't even, I can't even say it in a few, couple sentences. I really think it's going to save primary care. I really am a firm believer in that if you look at what's happening with the loss of autonomy and moral injury and burnout in the traditional model, I think, you know, that.
Doctors are just really the loss of autonomy. Caring for our patients is really a huge loss for us. And I think that this model will really is really important to be able to save primary care. I also think that it will save money, healthcare dollars. You know, we, we think about, oh, well, patients have to pay money, but if you look at the healthcare dollars overall, I really think it's this it's saves money in the big pie, the big picture.
And we need to start looking at how to cut down on wasted dollars in the healthcare system. And I, I think that you know, we need to start looking at unique novel ways to do that. And I think DPC is the way to go. I, I just think this is, this is it.
And for those people who have taken your words to heart in terms of the first steps, what would be, you know, the first steps that you would recommend somebody take, if they're exploring DPC and they're just really learning about what this movement is and who is
it, I would go to, uh, one of the DPC conferences.
So there's nuts and bolts. There's the head conference. There's the DPC summit. I would read one of the several DPC books out there. I don't want to name them all or I'll forget them, but. Paul Thomas has a great book and spark DPC has book. And, but there are several there's lots of books out there.
And then obviously this DPC podcast is a fantastic resource. And then lastly, you know, reach out to one of the many, many DPC doctors. Most of us are really passionate and ready to help and mentor anyone who wants to do it. That's what happened to me. Lots of people, you know, told me I could do it after I was like, oh, I don't know if I can do.
And you know, they said, yes, you can. And here's how I think it's believing in yourself, you know, none of, most of us weren't trained in business. So I think that's a huge leap. I think it's really unfortunate that, you know, we don't get that training in medical school. But the neat thing about DPC is it's a pretty simple model really, you know, with the billing.
It makes it very, very simple. So, you are your best, so you are, you are the resource and I think you have to remember that you really hold the power there. So I think we're so used to feeling like little pawns and, you know, we have, you know, we have to do what people say, but, you know, You you have the education, so you can, you can start your own practice and be your own boss and take care of patients with those
words of empowerment.
Thank you so much, Dr. Cornfield for joining us today.
Thank you for having me
*Transcript is generated by AI so please forgive errors.