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Episode 78: Dr. Clodagh Ryan (She/Her) of Cara Direct Care - La Grange, IL

Direct Primary Care Doctor


Dr. Ryan and her stethoscope
Dr. Clodagh Ryan

Dr. Clodagh Ryan is a board certified family medicine physician. She grew up in Ireland and graduated from Trinity College Dublin Medical School in 1999. After working in primary care in Ireland for a few years, she moved to the western suburbs of Chicago where she completed family medicine residency at Adventist La Grange Memorial hospital and spent 8 years in private insurance-based practice. As the medical landscape became more difficult for the independent family physician, her disillusionment with medicine grew. She switched to direct primary care (DPC), opening Cara (pronounced CAR-UH) Direct Care in 2017.


Ryan also serves as adjunct faculty and preceptor at Chicago College of Osteopathic Medicine. Her roles include course director, lecturer and preceptor of medical students.In 2020, she developed the virtual elective, “Introduction to Clinical Practice with Telemedicine.” The elective includes instruction on the U.S. health care system, health insurance, and the corporatization of medicine.


Dr. Ryan spends her free time playing Irish music on the concertina and fiddle, with her husband and four children who are also musicians. Her other hobbies include running and reading. KEEP READING TO SEE DR. RYAN PLAYING TRADITIONAL IRISH MUSIC!


 

Dr. Ryan will be speaking at this year's DPC Summit in Kansas City, MO


 

LINKS/RECOMMENDED RESOURCES:


CONTACT:

T: 708-571-2272


SOCIALS:

IG @Caradirectcare


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Dr. Ryan Is Featured on NBC News in Chicago - Oct. 17th, 2018



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Read About Dr. Ryan in the Chicago Tribune - October 20, 2017



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Watch Dr. Ryan at the 2019 DPC Summit in Chicago


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Watch Dr. Ryan In This Traditional Irish Band


 

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Transcription*

Welcome to the podcast


Dr. Ryan. Thank you, Dr. It's such


a pleasure to talk with you and you and I have, have seen each other in person once, but we've talked many times apart from this podcast. And one of the things that you have said publicly is that


"DPC is the most fulfilling way I've been able to practice medicine in my 20 year career while being a wife, mom, and musician DPC allows me to have a life while still being the best physician that I can be. And so, you know, just tagging along with your intro statement, I wanted to start with your journey into medicine. So can you please tell us about how it was growing up in Ireland in terms of your care, your family's healthcare and what pushed you into becoming a doctor?


So I grew up on a farm in the north of Ireland on item number six of seven children. My dad left school at 14. He was taken out of school when his father died and had to run the farm. So, my mom did go to college. She was a kindergarten teacher for 40 years. On the big thing for us as kids, we were pretty smart, you know, Booksmart was that my parents wanted us to go to college.


There was no expectation of becoming anything in particular, but my dad did always have this idealized version of Madison because his father, his GRA I'm sorry, his father, his brother, Dr. Daniel Boylan was a family doctor in the early 19 hundreds to 1920s or so, very close to this bridge that I have in the picture behind me here on the north coast of Ireland.


And my dad would tell stories about Dr. Dan doing highs calls and getting paid and. Chickens or eggs or whatever. On, he also would go out on the boat to Rosalyn island, which is about five miles off the coast, where you're sitting in my picture behind me here to deliver babies in the middle of the night and stuff like that.


So, so that was the idealized version of medicine that I saw. And to be honest, I didn't really want to do medicine because I didn't want to work that hard. I tried to find something in science that would fulfill me, but medicine just, you know, seemed like it would keep me interested for as you know, for a long, longer and longer.


And I still, I'm really glad that I did because there's always a fresh challenge and there's always something new to look up and to be interested in. So I was the. One who went into medicine. Uh, and I ended up, uh, I, as a kid, I was part of the NHS system, the healthcare system, they are Northern Ireland because that's part of the United Kingdom and still is.


So we had socialized healthcare. We could see our doctor pretty quickly. It was very, very short visits. Oftentimes you would see the nurse. Oftentimes the doctor wouldn't even see you that just calling antibiotics to the pharmacy those days. So I do remember a few, a few, we were pretty healthy kids, so we didn't have that many trips to the hospital or anything like that.


But I do remember, you know, having to go in the hospital when I fell and hit my head at a concussion overnight, and there was access to care for, for, you know, for the most part. What I find is that the access to care does get a little harder as you become an adult with larger problems. And those long-term less urgent problems can sometimes take a long time to get on the list to get treated.


So I hear those stories from my parents and my siblings over. I went to medical school in Trinity college in Dublin, which is actually a different healthcare system. It's the Irish healthcare system, which is pretty, still, mostly socialized, but there is a larger private area. Wing to it. So it creates a two tier system.


Those who have enough money will have a health insurance, and then when they do get sick and they have to be in the hospital, they'll get more likely to get a private room in a private floor versus, you know, the public floor that might have six beds in one, one room. And so that's where I did my training.


I went from high school right into medical school and a six-year program in Dublin. And so, we saw the gamut. I mean, a lot of it was pretty similar to what you'd see here, but it a lot of volume and a lot of people waiting for things, uh, ER, is, we're always chock-a-block full.


And when I did work for a few years after med school in Ireland, before I moved here and the big thing I always remember is that I had to affect three-minute visits. I would see, I dunno, 40 patients in a day. And I, but I would have 1, 1, 1 line. I mean, I, it was short and sweet. We have screen, we had little sheets of paper and we'd write down three lines, the pertinent stuff.


And that was it. But if you got somebody who came in the door and they had a, you know, a particularly bad story, I would be way behind with my patients. So that was incredibly stressful as well. And the other thing was that if we have somebody who we thought we needed to send to the ER, you really wanted to make sure that it wasn't something treatable as an outpatient because they would be going and they might still spend 12 to 18 hours waiting to receive no chest pain.


For example, if it was an anxiety, almost like an anxiety, chest pain, you'd be like, okay, is it really, I mean, what are the risk factors here? Do they, do we really need to send them? So I didn't like that either. And At that time, I was also playing in a bond. And so I was doing mostly moonlighting to pay the rent.


But for after a few years, I was like, this kinda stinks too. So, uh, when I met my husband I had met him years ago prior to that playing Irish music. But when we decided to move here, I was kind of, eh, you know, I'm looking forward to a fresh start to see if something, you know, high I would to try a different healthcare system where it wasn't so overloaded on access to care.


I felt like it was a little bit easier to achieve. So that's, that's what led me here. In the early two thousands after I got.


And it's amazing. And, you know, it's, you come from such a wealth of knowledge, your experience in a different healthcare system, as a kid, but also, you know, in private practice prior to moving here.


So I want to ask, especially for those people who might be, coming over to the U S too, start residency, even though they're already a fully practicing physician in another country. What was that transition like to. Chicago area. When you started in your residency program here


that was it. I was one of the toughest times of my life, even though I was a newlywed. And I think that it's, it actually took me about two and a half years to fully, fully, fully transition into medicine here.


Some of it was those darn us Emily steps that I had, I was going back to like early med school biochem, et cetera. And that was really tough. So it took me a long time. I took a Kaplan course. I ended up having my first baby in that time on them trying to get the externships, getting the experience, the work, the letters of recommendation, et cetera.


And one, I feel like my first three months of, of residency were absolutely insane because I was learning a totally new system and a totally new system of charting and everything. But I also felt that. Those two and a half years were time. I would never, I never stopped working again because of that.


I always worked part time through having babies, et cetera, because I felt like that time out of medicine was very difficult to transition back into. But I, on day one of residency, I was lucky enough to have a great grip, a great class who were still in touch and were best friends. And I, so I feel like once I got my, my group I was on the same footing ban as everybody else.


And, and to that point, I think that I also had a little bit of head start because I'd had so much experience. And so a lot of the patient interaction, et cetera, wasn't hard for me. A lot of the differential, et cetera. It was more the system learning that was difficult. I'll never forget. I tell my med students this.


My first day of residency, my nurse handed me a blue sheet with like all the CPT codes on the criminal level, one level sire. I was like, what's this your billing sheet? I was like, okay, what do I do with it? So my nurse teres Jeddah to Teresa from residency she took me under her wing and she, she taught me all that stuff.


I just always thought it was so, superfluous to what I was supposed to be doing. And you know, that's, that, that was just it. We never had any of that in my old, you know, in Ireland at all. It's just, you get the, get the, get the patient visit done. You take care of them, you get the medicine prescribed and then you move on.


This is, this is exactly what I was gonna ask you next was, when you moved and you went through residency, were there other things that you were like, you know, I was really hoping that this would be how the us healthcare system would be like, and did you find anything that you are glad to see in the U S healthcare system that you didn't see in Ireland?


So I feel like, you know, the story changed in Mike between beginning of residency. By the time I started my DPC practice, because as a teaching, the course that we're going to talk about later for the med students, you know, Ababa care, ACA affordable care act happened right in the middle of that time.


And that changed it for a lot of us working docs at the beginning of residency, I would say, I, you know, we didn't see as many. I love the the ability to be able to really get into the story. I did have a lot more freedom to be able to get patients to the specialist or, you know, the care that they deserved or have them come back for follow-ups or even just getting into the therapist at our residency program.


But you know, in the first three years you start to see a lot more patients. So by the end of it, and then private practice, you start like, you know, just knocking them might, you know, hon Hondo on the door handle trying to get to the next patient. And the patient, you know, has got three more things to ask for you.


And then it became more and more tricky to get what they needed. The prescriptions at the pharmacy were denied. And you had to write a prior authorization for, you know, an SSRI that costs one to one 50 a month, or, you know, there, you couldn't get them in to see a specialist for three months, but you, you know, so we had to make calls.


And that was that, but that, that was not the case at the beginning of my American career. But it was by the time I started DPC, it was very much a huge time waster for us. When you just wanted to take, you know, to do the clinical medicine part. I do. I do like the fact that I don't have to really think of it, sending people to the ER for the most part.


Not that I do for a cash reason, for a pricing reason, I try really hard not to send them to the ER. But I know they can get the care that they need when they need it at the ER, too. So, so that part is really nice. And I also have made it a huge goal since I started my DPC to, to have connections with a lot of independent specialists in the area.


so I'm able to get most patients the care they need in specialties because I've developed those connections um, on most of the time cash pricing. So for example, I have a new, a new patient who, who pretty much ripped a hole in a shoulder and uh, he needs surgery. He's, uh, he's a, uh, hardworking gentlemen on his employer called me his employee as my patient.


On, we did an MRI on his shoulder assist, you know, he had an accident at work and it's just ripped to pieces. So the surgeon that I know in the area, I texted him on. I sent him the MRI report in Friday and he sent me. He w he, uh, a whole list of all the pricing on he's going to see them for free for the first visit.


And then we're going to work on getting him the surgery that he needs. That's because they built the, you know, I feel like it was easier for me to get that because I built that relationship a couple of years ago with the surgeon. And he's very grateful to be able to help our patients when I need it.


He's done. I think, two other surgeries for patients of mine before.


I think this is so cool though, because you have such, like you said, you know, when you started residency, you had a very different training background, but in general, you have a very different bird's eye view of how people can be treated as patients in different systems.


And you know, what the ideal system that you could build would be for your patients. And so I want to ask there, how did you go from your private practice to learning and then opening your DPC?


So, it's funny because I was, you know, I think probably like many of my generation of DPC physicians that, you know, the ACA started to change things for us.


And I didn't even know. No. What, what, uh, those first few years and I was lucky enough, I wasn't overburdened with all the stuff that we talk about any, you know, but I wasn't in a corporate, uh, practice. I was with one other doctor who was self-employed for years and years. And I feel like that also, I learned a lot from him.


I watched him running his practice and it was more than the insurance side of it that, that kind of burned me out. And plus I realized that I did want to be my own boss and you know, it, he, it was his practice, so he didn't really want to share it, you know, full-time long-term with me. So, I feel like when I, I transitioned, I was starting to be.


Uh, and I I was spending way too much time charting at home on the days, and I was part-time, but I had four little kids and I tried to be present for them on the days I was off. But I was charting during their nap times on, you know, just getting frustrated. And my husband was getting frustrated too, because they were spending too much time in the computer with the computer.


So I started looking around and I, I have a friend in biotech. So I reached out to her. I looked at, you know, pharmaceuticals and I talked to a few other doctors are considered concierge medicine. And I just didn't didn't appeal to me. So, uh, considered occupational health, all the different stuff that I think we all go through.


I knew I didn't want to go to another practice or a corporate job. I knew that that would be worse. So. Then one of my teachers in residency, she was three years ahead of me and then came back in my third year to be a preceptor. Her name is Dr. Szeto Bhargava had started her own DPC practice about a year and a half prior to mine.


And we had, one of my residency, classmates had worked with her in her previous PR private practice. So we had this connection. I'd hear how she was doing for my friend, Teresa, Teresa, Dr. Teres, and she, and so eventually I called GTL and I said can I meet you for breakfast? Because things were starting, starting to unravel in my other, in my other job, Miami had just laughed.


And it just, the, you know, things unraveled at that point. And I still remember it, the light bulb moment, an hour of breakfast, and I was sold and I have a picture of that day. And I tell her that's the day that my life changed I went home and I told my husband, I want to start a DPC practice.


And he said a, what? 10 mentioned it to him before. So that was January, 2017. And that then I, the state, the idea started, you know, I started then I started really researching. So I think a lot when I, you know, when I, when I talked to other docs who want to start a DPC practice, that, and everybody does it differently, but I immersed myself in DPC, everything DPC.


When I was cleaning out a closet, I was listening to a lecture by one by Julie Gunther at one of the, you know, nuts and bolts re you know, or if I was in the car, I was listening to another party. There weren't that many podcasts, actually, at that point, it was more YouTube videos of lectures. And I listened on, I read and I got all the, you know, the books that I could.


And I mean, there's a wealth more thing, you know, especially, you know, your podcast, especially, but even more books written since four years ago, you know, so, and I talked to, I, I joined the, uh, one of the Facebook groups and I contacted a few people who I thought had a similar way of practice that I wanted to achieve.


One in particular is Dr. Kissy Blackwell. I called her, she transitioned her practice three months before mine. She grew way faster than I did. So I always felt like, okay. I mean, if she can do it, I can do it. One was Dr. Rebecca Bernard in Florida. She, she was wonderful. Every single one of these people that I called or texted.


Well offered me their time on a phone call, at least one phone call. If not more, every question, Dr. Szeto. Oh my gosh. How many times did I call her? She was so kind and sweet. And so that was one of those things that was, I have continued to pay it forward. And I think people who I have mentored continue to pay it forward to.


And I think that's one of the lovely things about our community. So I immersed myself. I told my office current office manager, who was my, was my front desk lady and the old practice. I told her in February she left in March. I given my notice in may I left in June, end of June. Uh, I did my first time hall meeting in June.


I was very lucky. I didn't have a non-compete. And so I sent her the letter to the patients as soon as I gave him. The first person I called when a hundred and my notice was another doc I heard was retiring or in the corner. So I called her and I said, can I come see your stuff? I'd like to buy some more?


Yeah. Sent the letter, did two town hall meetings, one in June and one in August. Uh, 50 people arrived for the first one. They all signed up and some of them brought their friends and family and they signed up to nine came for the August one. So not very many, but they all signed up to, and most of them actually are still patients.


So, I can't emphasize enough the town hall meeting. If you have the opportunity to take patients with you, let them understand the model by talking to them about it. And I have not done any public speaking for 15 years and I was so nervous and so sweaty and it's still on my, my website, actually that pot, that very first meeting that I did because I feel like your patients.


And they're sad that you're leaving and the ones who come to that, those meetings really, really care about you because they want to know what's happening. You, you, you accumulate more patients along the way later that are there more for the financial benefit, or maybe they've been burned by another, you know, corporate practice or something like that.


It's less about you, but those patients at the start I'm still getting patients who, who emailing me, who from my old practice saying, you know, we miss you. We want to come be your patient. How does it work now? You know? But it is also interesting because, you know, I think I had a little bit higher than the average for people switching over, transitioning over from your private practice to a DPC practice.


I want to say the 10% maybe. I think I ended up with a by 20%, but not all have stayed. You know, we have churn like everybody else and some people move on, but I'm still a. I'm still getting more coming on. And some of those people joined that that September, and they're still my patients four years later because we had that connection already on neither even we have a deeper relationship because we have more time together so that, you know, I think that's the big thing.


I always tell people, considering it learn about it, read about it. I mean, I went and I watched town hall meetings that people had done for their practices. I contacted a few people who had done that, you know, every, every step of the way I tried to find somebody that had done something that I thought would be helpful and that the, you know, the general DPC community had recommended on, on that all that hard work paid off.


Because then when I, when it came to marketing or selling myself, I really knew all the answers to all the questions very well. And it didn't come across as I was, you know, had no idea what I was talking about. And I did, I think my first, my first conference I went, yeah, Was in November, 2017, three months after I had opened and I already 150 patients, I opened with 98 patients.


I had, I think 75 other by 10:00 PM the night before I opened and I went to bed, I had this whole you know, waive the enrollment fee. If you sign up before September 1 cent, everybody had an email list from my old practice, sent everybody the email I woke up and I think another 25 people that signed up something to that effect because they didn't want to miss out on the, on the discount.


So I opened was 98 and it grew, grew fast. I had another event in that December with was the open enrollment, no enrollment fee at my practice. And I got another bunch. So I, by three months in, I had 200 my office manager started with me at about five hours a week, but it grew very fast. And so it was drinking from the fire.


For about a year and a half. And, uh, but I always, you know, I kept in touch with Dr. Blackwell and her firehose was much bigger than life. So I always felt like I was because she went to 706 months or something. And so we, we capped out at about three 20 and that would have been just pre pandemic, like fall 2019.


At that point, I dotted a part-time nurse, I think about nine months prior. And we had started to stabilize and I, I pushed it up a little bit. My on my, on my thought had been around 300 for a while until my, so my kids are, I started my DPC a week, a week after my son started full day school. So I was in your position for years.


And when the kid at home, you never really get anything done on those days, you're off because you want to play with them. You've got that goal to get work done, but you want to sit in the floor and play with them. So he started full day school and a week later I started. Definitely full time. I feel like it was full-time in school hours for about two years, maybe one and a half to two, but now it's not, it just was so much fun too, that I really did want to want to work on it.


You know, I wanted to build it. I wanted to streamline it. So by 2019, I feel like we had you know, gone to that level. And my two office, my office manager and my nurse are part-time unlike being part-time. So, uh, at that point we started to started to bulge a little bit either. I was going to have to work more hours than I wanted to, or, or they were going to have to take on more and they didn't really want to, at that point.


And I thought about it, a third employee was not, you know, enjoy, like, I it's good to have the two, but I didn't want to have a third person to manage. So I decided to back off a little bit. And then I did get the opportunity to build a course for the med school. I think we're going to talk about that so that.


Me, I I've, I have actually trended downwards a little bit since the beginning of the pandemic. So we're now at around two 70 and with the teaching as well, because I do spend some hours every week on that that it is very doable and it's very much it's not a full-time job anymore, even with both jobs.


And I think, you know, it's less, uh, at this point it's definitely less hours than what it was doing before evenings and weekends are free. Wednesdays and Fridays, for the most part, a part from my teaching are free. And we're still busy, but it's not nor it, it has, it has worked out very nicely, but it was a, it was a hard slog for the first two to three years.


When you talk about this idea of building and streamlining your practice, I want to first talk about team building because you, you shared how, it was Paula, correct?


Uh, that was your front office person. And is now your office manager, when she had left in March, when you had, you know, handed in your notice in may, how did you guys even collaborate together to have her there on opening day at current director?


I was lucky that Paul was there from the first day of my, in my old practice.


She had been working there. I think she worked there five years before I, before I came and she didn't have that many hours and I was starting a new doctor. And so, my boss offered her if she wanted to work with me on the days he was off. So, so then, you know, we, after several years, of course, with all the, the busy-ness of the regular private practice, it did get very stressful at times, but we worked well together and Paula and I are lucky enough to have be able to be upset with each other and labor at work and move, you know, move on.


Neither of us can't hold on to that knee or, you know, and she is, she's been very much in personality, very much like my husband. So there's, so there's a good connection or too. So Paula was Paula was on still is the number one advocate for direct primary care for Carra direct care on for the success of this practice.


And Unimin, Paula will go to the dollar store for something and she'll buy some organizational things for, for the office. I think we might need this. She tells people about it. She has read all the books like she's really very much has been an advocate and really believes in the model on, on, on that is, that's hard to find.


I think that a lot of us don't have that in our inner DPCs. I just got really lucky and also I do, you know, try to make sure that. The job is good for her too. She probably you know, she has a lot of flexibility and you know, they work from home a lot if we don't have patients scheduled, you know, answering calls from home and things like that.


So, so then with the pandemic and we knew we had to really tighten our social circle and our work circle, Paula and I have become even closer. She is going to have surgery on Tuesday. So two days from now and she's going to be out of the office for a few weeks. And I am like crossing myself, you know, praying, praying that we don't all fall apart.


Maggie is the nurses wonderful tuna and kind of knows a lot of it, but Paula knows where everything is. She knows how everything works and, and I'm, I think we'll be fine. And, but this is, this is, you know, she's always been like, just call me all I'm going to be doing is sitting around with my leg up, you know, that sort of thing.


So that is. Uh, person to find, but if you have one of those and you can take them with you or, you know, persuade them to come work for you, treat them well you know, share, sharing your success with them. So I've, I mean, Carter cares as much Paula's as it is mine and she's, you know, the biggest advocate.


So on my knee, I and Mikey came in actually as a patient and we got to know each other and her family, et cetera on then I was looking for someone, I wanted an RN, so she could, you know, dispense draw labs, do all the stuff, but also triage. Um, And it, she came in, I think about a year after she became a patient.


And it works well for her life as well. And she has, it's really nice because last summer, when I went to Ireland for three weeks, Maggie came in a couple of times and saw patients for me on FaceTimed mean, you know, did strep tests or like we, you know, kind of triaged the patient for me over the phone.


And we were able to monitor. Not to lean on our, on our covering ducks because the stuff that came in through the door was, was manageable with her in the office and me on, on FaceTime. So that has been wonderful too, because then I have a little bit more ability to go away. , and, our covering ducks didn't get one call in over three weeks last year because of the planning that we did.


And you talked about the streamlining era. I mean, I think the first day we opened, we, it was unbelievably disorganized, but we went paperless from the start, but day, day, one, and day two, we hadn't got that figured out yet. So I had to scan in and, you know, the contracts and everything.


I was like, oh, this is not happening. So that was very. Because that was a new skill for Paula and I to learn too. And we're not particularly fast at learning all the new softwares and stuff, but we try really hard and we make it work, but I feel like we're still learning a lot of this stuff. And, uh, we, but between us with trying to figure out what works and we've got a pretty good system.


That's awesome.


And, highlighting what you did, what you've mentioned before in that, you know, patients really follow you and they understand generally who you are and they understand a lot of the times why you're, why you're choosing to do a model electric primary care.


I feel that patients are very understanding and forgiving sometimes when we're building our, you know, our workflows out or changing our workflows and things like that. So I'm glad that that's, you know, that your, your experience opening was drinking from the fire hose, but you've, you've made it work. So I want to ask there, in terms of when it comes to the business side of your clinic and the workflows of your clinic, what have you.


found that was a really good business policy to have, or a workflow to have that you've implemented or changed over time.


So yeah, one of the things about the electronic forms, and I think we're still in the midst of this, because it, to us, it's kind of an overwhelming task because we're both, you know, a generation ahead of you.


But they, we, you know, I said we started with paper and then quickly we used, we got it on, you know, online in Dropbox and we used a PDF editor app on an iPad. To open up a contract because I usually have the patient, we go through it on that first visit. We have a list of criteria by DPC that they need to understand and that they initial before.


You know, w as we sign it, I feel like when people sign up online with their enrollment form and whatever, they just click the link, they don't always read the contract. So, it just that expectations, but on the PDF editor app, it was 10 bucks or something. So it was great, very, very cheap, but clunky because we, you know, Paula would have to go through, when were you see a new patient, she would be putting in only initials and then just kind of like, we'd have to scroll through and get them to sign twice.


And that it's just clunky, but it worked for a long time. So now we're working on getting that really like a, you know, an electronic form kind of. I don't know that we use bronze here, but we've got one where we send a link to to the patient and they do it themselves and they can do it from their phone or they can do it from the website.


Uh, I'm sorry, from the link on their email, but they, uh, the issue with that is that it takes a long time for each one just to get each one right on that too. So it's almost like we're rebuilding all the forms. But that's okay. We're taking it one at a time. We've got a few of the very common ones we use that are done on I'm, you know, trying to build that into my admin time as to kind of work on that Paula and I too, we're both, you know, we work on it together.


Sometimes we've had some mentorship from Shaddai to Madison at Dr. Tommy water's office did a zoom with us one day. They have got it all figured out. And, uh, you know, that's the kind of thing I reached out to Dr. Tommy and said, I know you use this particular software, you know, w w she said, oh, Madison will get, Madison will teach you.


So, so that has been really helpful, just, you know, camaraderie between office managers and Paula really enjoyed that, too. So that was a big thing. We are still on some, a lot of, uh, street, uh, the. Streamlined or like the, the, the cheaper version of a lot of stuff. It's not that we have to be frugal anymore, but Google voice, we have a Google voice office line, and I know a lot of people move to something that is a subscription, but this one has worked for us for the most part.


We have a Doximity Fox, that's free. That's a little clunky. We're still trying to figure out which one we're going to switch to, but we haven't done it yet. Because that does take time, staff time, more staff time. And then I, we use a. We were using some paper forms for mental health and things like that.


Screening questionnaires. We're trying to get those online onto our online as well because we use them so much. Uh, haven't done. Haven't got there yet. So the patient will, Paula has a bunch of like paper forms as well. She knows when, when I come out of the room and I'm like, can I have this farm, this farm.


She has a whole, a whole concertina folder that works for her. Uh, we have a few other things that are still on paper, like our prescription ordering. This is, uh, this was one. Best things. I think there's a couple of things. I know Paula invented a signup sheet for prescriptions that were picked up with initials only, not with patient identifying features.


So it's like patient's medical record number, prescription number dates, and initial to when they picked it up, because we did have, we have had a few patients who forgot. They picked up their prescriptions and they come in again that only a couple, but it does happen. So for us to know, okay, they did get, they did get picked up and we have the you know, that, and then with our prescriptions, we streamlined it during the pandemic lockdown, we have a little bit more time.


So we always wait for that $100 of order or ordering wholesale meds to get the free shipping. But that meant our prescription ordering was all over the place. So we increased our percentage a little bit on the prescriptions to cover. Then we order on Thursdays, no matter. Even if we don't have, we, generally these days we do have a hundred bucks, but we do order from two different wholesale wholesalers.


So sometimes we've got some in one cart and some in the other. So we would order Thursday afternoons people know that they needed, you know, they won't get them till they come in. And Monday's mostly inventory done Monday and dispensed. And Tuesday morning when Maggie comes in, because she's not here on Monday.


So by 10:00 AM on Monday, most time people can get their prescriptions or they're shipped to the patient at that point that has helped a ton having a routine. And then the patients start to get used to it too. And every, so often somebody says, oh my goodness, I only have two pills left or whatever. We say, okay, we can get it overnight, but, and you can bring, pick it up tomorrow.


You just an extra $10 charge on, they're fine with that here and there. And most people are used to it. Like we have a whole system on people like that structure to, , I think that helps a ton with. Uh, even a starting practice because all the, you know, that back and forth and never knowing when the meds are coming in and if you're a part-time or your offices is closed, so they get bumped to the accountants across the hall, and then people, all, you know, is my mad red ready yet for pickup on you're in the middle of, a full clinic.


And you haven't got somebody to help you with the meds dispensing. So having a routine on that, I think because that's a special thing that we do as DPC docs, it can get overwhelming. And I think that has helped us all a ton. I'll tell you that this week when Paul was not here and Mike and myself are, are running the Mads, but in general, the girls like it too.


Do you dispense meds for.


So I do. I because currently I'm still telemedicine and home visit. On the way to a patient's house or I'll be in the area, I'll just drop them off at a patient's house. So that's, that's generally what I've been doing, but it's, it's so wonderful because my patients have had my insurance won't cover my list in a pill.


I can't make it to the pharmacy on the day that I needed and I'm gonna run out before then. And so that's been a use case where I've been able to bring medicine to them and they have, , an extra supply so they can have coverage in case that that happens again or it's Thanksgiving. And there's no pharmacy open locally, so fancy that I have some Macrobid and Catholics in my supply, you know, it's, it's really, it's priceless when it comes to being able to give our patients access to care.


So I love that you guys have the system and that's, I think that's such a gem in terms of having a routine because we thrive on routines and our patients thrive on routine. So


Yeah, absolutely. And I think my, my favorite story about the one you're discussing, so I had this patient who was homebound Alzheimer's care.


Full-time caregiver daughter lived in the area. And she would get UTI. So he actually passed away last year, but she would get UTIs. And I think I was finishing up work one day on a Thursday afternoon, uh, five 40. And I saw when the daughter called, I would always answer because I knew, you know, she was, she, she would get sick quickly.


So, so I answered the phone and everybody else had gone home and she was having increased confusion. They just wanted to make sure she didn't have a UTI. So this lady lives right behind me that, and I was able to at 6:05 PM on my way home, I dropped off I've specimen jar on an antibiotic. And so within 30 minutes, without any caregiver having to do anything, I was able to help that patient.


It was just kind of, you know, it's nice to be able to serve people with. Yeah. And not have watched them go through the system and be frustrated and waiting. And yeah, there's a certain element of those, you know, those ladies that lady's daughters would have done what needed to be done to get that. But I was able to, I was on my way home anyway.


I said, I'll just drop it off. No problem. Yeah. So yeah, it's really not, I don't always have the right on prescription in my office. And I have learned that there are certain ones I use more than others and I'm starting to not order some of them and just send them to the pharmacy. For example, I've never had suspensions for kids like amoxicillin and stuff like that.


They're just a little trickier on there, just so much. They're just cheap. So, so there's certain things that I, you know, it's very, you have to be very careful not to order all the things you think you might need because a lot of them will expire and then you just pay for those. And I think we all learned that along the way on checking good racks and making sure that.


You're not dispensing something and using staff time to dispense something that's just as cheap on good erect. So then we're not getting compensated for our time. So there's that balance there. But then when it comes to patients who I just ordered a year supply of, you know, of something for a patient who I know comes in every three months anyway, you know, that just kind of like that, that saves a lot of time for them calling, picking up the prescription, et cetera.


So it's nice to be able to do that.


Yeah. When you mentioned the year-long supply I have a patient who's on a PPI and their insurance only covers 30 days at a time. And the price for the PPI with the insurance was like 25 to $30. And I was like, what if I could get you 2.7 years for the cost of less than a month of your PPI for the exact same PPI?


Yes, that's exactly what I just ordered was one year's worth of it. Oh. And it's an over the kinder PPI, but it's much cheaper through us. So, that's just that, that's nice. But I do feel like we are, we're trending towards , the dispensing is more for the long-term chronic stable pain or you know, stable medication patients.


And then when we're adjusting that. Or, you know, so a lot of those, so I don't keep all the antibiotics in the office anymore because they expire. I don't, I just, patients have not been as sick the last two years too, because of COVID is the only thing we saw for so long. So a lot of my PR antibiotics expired.


And so I'm trying to keep just a few of those, but it is very nice for them to be able to, you know, walk out the door with their prescription.


Absolutely. And when we're talking about pricing, I want to ask about overhead because that's a big thing that, people who are, you know, they might have, loans that they're paying off, or they might have a family that, where they're the primary breadwinner.


How did you develop your business model to make sure that your overhead was working for you and allowing you to have the practice you wanted to have?


So, so when I started DPC, I was, I started DPC to get to stay in medicine, not because you know, not to like make more money. I think that was the big thing for me.


I also, you know, my husband is not in medicine. He is a full-time and finances, a spreadsheet guy. And so that has always been a nice balance for us because one person in med. Is there always a little bit more work a little bit more hours and things like that. So I always, I kept my overhead done at the beginning.


I bought retired physicians, uh, equipment furniture, and most of it I still use. And then I also, the office I'm, I'm sitting in right now. It's like a three room, 1200 square feet office. And it's in, uh, it's in a building with five other offices, one to three dentists on a hairdressers. So he's right across the hall.


We, we, she, she takes care of all the little old lady. So it's permed day on Fridays at permeant underneath our door. So this doctor, I knew her names and it's really close to my everything in my life. So my old residency is two blocks. My house is right across the street from my old residency.


Ironically, I didn't live there in residency. My, my kid's high school is right in between those two things on my kids grid. Skull is about a half a mile around the corner. So very, very convenient. And I I've discovered as a mother of four that wasting time and commute is never a good thing. It's like literally three minutes from my house.


So I really wanted to have something close and I call this lady. She was still working at the time about probably a byte April or May, 2017 and said, can I sublet a room from you? Uh, and so I did for a year and I paid her rent and then she said, I want to retire. Do you want to buy the office? So I bought the office from her 10 months in, and that was, that went.


So my overhead went from probably. 20% to let you know, maybe 15, 20%, because I was on that low rent and everything was very, very frugal, but then I had to kick out the office and I had a mortgage. I had taxes and all that sort of stuff. Um, And redid the, I did a renovation, uh, construction on renovated the office.


So not it's, but so now I own this office, but my overhead is higher. And so one of the things I did do pre pandemic was started to think of, uh, our odd sub ladders. And, uh, we, I had two mental health therapists, uh, subletting for awhile, the pandemic kind of decreased that they're not here right now, but my overhead is probably a higher percentage wise than I would like.


And why is that? Uh, you know, obviously I would like to make more money and not have as much overhead, but I think it's because of where I am. In that mode, the number of patients on my panel on four, I in my family life the buying the office was an investment and one of the goals would be either to add more patients, add another practicing physician to the DPC or sublet to other, you know, specialists or other doctors or other uh, people like therapists, et cetera, in order to, to decrease my overhead.


I'd say probably 30%, maybe 35 which I, you know, I don't really want to add more patients right now because I'm enjoying the teaching, et cetera, but it's definitely a goal to maybe get somebody else in here to use this on the days that I'm not using, I'm not using it. It just has the pandemic and everything has just kind of changed the, the, uh, you know, that people were not taking risk and starting new things.


So there wasn't really anybody. For a long time. So now that we're moving past that hopefully a little bit, I'm hoping to get to use the space more, but I do use it myself for a while. We had a music teacher on Sundays who was using the waiting room to teach our kids, that Irish music pre pandemic.


Since they, since everything opened up, he has decided not to come back. So on Wednesday nights now I'm teaching Irish music in the waiting room. So that's.


I love that though. And, you know, it's, it, you're being creative. You're thinking out of the box when it comes to, you know, other people using your space, but also it's just really important that you shared that for people who are planning, especially, you know, in the next year or so to open, because they can start playing with the numbers.


Like if I have this, what would it look like for my overall budget? What would it look like for my overall overhead or investment that I have to have going into DPC? So I think, you know, those are extremely helpful. Parts of your practice to hear about. One of the things that you had mentioned that I want to go back to is when a patient joined your practice in the past, when they, you know, when you send people off your waiting list, now you said that there's a criteria for patients to join your practice.


So I'm wondering if you can share a little bit about how onboarding works for your patients, how the discovery calls happen in terms of, you know, when someone's interested in the practice, they're saying, yes, I would like to join. How do you see if the patient is going to be a good fit for you? And.


So great question.


And I think that also has changed a lot and I think it's very natural for that to progress and change when you're first starting, you are you know, you just love people calling and you want to give them the best help. Then once you get to a panel where you're happy with it, and you have the ability to form a waiting list, you can choose to do it different ways, but the way that we find works best for us.


And actually we just got a new workflow for this recently within the last few weeks, we decided that so what do we do as PE patients will usually reach out through the website. They send a message, you know, I'd like to talk about joining the wait list or they send an email and they say I'm a.


The X patients and she recommended could, you know, high, does it go by, hi hydro, I joined the practice. So generally Paula or usually Paula or Maggie will call them back, answer some questions, but then schedule them for a phone call with me. And it used to be weird fit the phone calls in between clinic patients.


But then the phone calls would get a little bit dropped because they just, you know, it just, things would get a little crazy around here. I've got med students following me around too. So, so within the last few weeks we decided to the phone calls on Wednesdays just before. So Wednesday, lunchtime is now when, if we can with a P a prospective patient, we see, even if they call on on Thursday the week before we say, oh, Dr.


Ryan does calls for new patients on Wednesdays. Cause then that's in my schedule. So that's working out very well actually, because I, then I think about it, you know, and I feel like on the first impressions, it's not good to miss a call with a prospective patient because you're seeing clinic patients and have to call them back a few hours later and say, sorry, I forgot, but we run out of time or whatever.


So I think that that was bugging me a little bit because I felt like they would, you know, that wasn't good for, from my perspective either. So then when we do call them, you know, I usually ask, where are they. The practice and what do they know about DPC? And I get a good handle on where they're coming from and why they want to be part of the practice.


And I get quite a mix of patients. Uh, I got a lot of access to care patients, so they may have there's a, this is a relatively middle-class neighborhood, you know, on a lot of people are more, I'm not being heard. I can't, I don't, I need an advocate because I've got XYZ, chronic conditions and I'm, and I'm so frustrated with not having enough time to be able to, you know, have somebody to help me.


So there's a lot of those. And then I get, you know, the employers calling or the uninsured looking for, you know, something or the large families on some. And I got a lot of I've recently I've been having a lot of 40 year old wives calling who's who of this is very common in the Chicago area.


They all live in this. And then they have their babies at Northwestern and uh, very well, you know, well, well, no one maternity, right? So they go to their OB for 10, 15 years. Uh, they move out to the suburbs. One where I after baby I'm on baby, number two is on the way on then, you know, they're busy having babies, raising them.


And then when they hit 40, they're like, okay, time for me. I don't have a doctor. Right. So I've had a bunch of people joined in that stage of life who are very health conscious, and then they get their hardworking husbands on board. And they're a very nice group of people to take care of because they're very appreciative.


So that's been kind of a nice little uh, demographic that has been growing recently because the word is spreading. Um, And it's usually patients who tell other, you know, other people on when they become patients who tell other people. So those, those phone calls are very, very important because I have developed the ability to understand what they need and whether they need it fast, or whether they really understand what we're doing at all.


And what they're looking for on, for the most part, then we put them on the wait list and we try to assess you know, when they need to be when, when they need to join. And I do think that the best DPC patients often are those who are willing to sit on the wait list. They, because if they're willing to sit in the way, listen, two months later, three months later, you're able to squeeze them in.


They're more likely looking for the long-term relationship. So that's been nice, most new, new DPCs can't really afford to play that, play, play that card, you know, but and then there's others who you can tell. They just really need somebody. And sometimes I won't bump somebody up the way. Sure due to need.


And we have a new patient coming in soon who literally needed a patient advocate with XYZ friend of a current patient. And I could hear the anguish in her voice. I'm like, she needs me. So, so it, it just depends. And, you know, we always get DPC or the people always say, you know, cherry picking and all that stuff.


I think cherry picking is boring. Like I like the difficult chronic condition stuff. I like the challenge. I like to see patients who have, you know, 20 medications on board on try to, you know, create the best quality of life that I, you know, can achieve for them. So we have more time to do that. So we do, I think I'd be, you know, cherry picking those healthy patients.


I think that's not that much fun as it.


Yeah, no, I agreed. And I just, just so many things come up in my mind as you're, as you're speaking there, you know, I, I, in my old practice, I remember, when a patient called, , our new patient, panel was closed, but we saw people on the wait list and there was a person who had a recent cancer Gnosis moved to the area, couldn't get care. And, you know, if a patient is in that type of situation and then joins your practice or another DPC, it's not only the access to care that they get, but then it's like, oh, here's a doctor who also has the time to then go through all of the history to figure out what's the best way that, you know, the doctor can advocate for that.


Person's a patient. So just, I think that's so amazing that, you know, like for that. The patients who do go up on your waitlist because of need it's like they don't even know what, like this magical Pandora's box that they've opened is afterwards, because they've probably never experienced our PharmaCare.


Like, like you provide them. So I think that's wonderful. And then the other thing I think about is that, you know, with the chronic issues and the cherry picking, it's so interesting. I had, uh, I spoke with a physician who had tried to do a business model where it was just a fee per visit. It wasn't a membership model.


It was a pay as you go. They were in such disbelief that direct primary care could work for anybody who has more than two chronic medical issues. And, you know, just being a DPC doctor, speaking with a DPC doctor it's like that, just like it it's completely blows my mind. And I'm sure it blows your mind that the idea that when people have a relationship-based doctor, a relationship-based physician patient relationship, it's just, it's very different than it is absolutely made for in a lot of cases, those people who have multiple chronic issues, because like, for my, my patients right now, I'm seeing a lot of them are tied to lifestyle.


I think that that's a big thing that, you know, I didn't have the time to address before. So I think of those two things after.


Yeah, absolutely. And I think absolutely we, we have so much more time to get into preventive health on, and I think in order to even approach preventive health, oftentimes you need to build trust first and that we, I teach that to the med students too, because we talk a lot about you know, as, as you know, I do a lot of metabolic health, uh, on, you know, not so much weight loss medicine, but we do try to broach weight loss and getting healthy, et cetera.


But, uh, one of the big things I tell the students who ask, how do we talk about this with, with patients it's really hard. And I say, don't talk about it in the first visit on the second thing is don't get your nurse to weigh them as soon as they walk in the door. So, you know, bro, I, we take it slowly and leave shame out of it and be combative.


So much easier on a DPC practice because we've got plenty of time. And I feel like they, the nice thing about the chronic disease patients and then even the sick ones and the ones who, because we all have patients who pass away. Right. Is that it's nice and it's not because every time a patient dies in a D in my DPC, it is much harder to process it's it's because the relationship has become much deeper, even those who were patients of mine and the old practice.


So, I, one of the ways that I I'm able to deal with it is that I offered to play music at their funerals. And so I get to say my goodbye through music, and I've done that now. I don't know how many times. Six, maybe I played it, uh, played at a funeral yesterday. It wasn't a patient, but it was that his kids are, my, his grandkids are my patients.


And mom was actually was a friend before becoming a patient here. So I played at granddad's funeral. I've known them for many years, et cetera. To be able to give that to the patients who, you know, that personal side of me, sometimes some docs might feel like that's crossing a boundary for them, it's music.


So I'm able to give a gift of being, you know, an and that's a gift to me too, because I get to say goodbye through that. And and having, uh, you know, not everybody maybe wants to have that, but it is something I do offer. If I'm able to, honestly, I can take the day off to go to the funerals. I mean, I never did that either.


Right. So, so it has been, uh, in that way, it's been very, very full. That's awesome.


when you talk about fulfilling, you've mentioned how you do mentor medical students and as well as other DPC physicians. But I want to touch on that too, because you know, you are an example of how you can craft your DPC to allow you to live the life you want to live professionally as well as personally.


And so you are on faculty and, uh, a preceptor at the Chicago college of osteopathic medicine, and you have developed your own course, you teach to medical students.


So can you please tell us a little bit more about how that even came to be and what, what is it that you are able to share with medical students regularly?


Yeah, it all kind of fell into my lap in a way that I didn't expect, I think going into DPC, I think I had this expectation that I would. Started to practice, build it at some point when my kids are older to full-time and that's what I would do just like I was doing for the last eight years, but DPC to opens so many new doors and it opened so many new sides of each of us that you didn't know where they are.


I think that was the big thing that I realized that in deep, my DPC has taught me a lot more than just direct primary care or medicine. It's telling me that I can do a lot of other things too. So, so, at some point I think in 2018, I started taking students in my office from, from Midwestern Midwestern university, Chicago college of osteopathic medicine and full disclosure.


And I am not an osteopathic physician. I wish I was, uh, we didn't have that option in in medical school in Ireland. Uh, osteopaths in Ireland are more like chiropractors they're, they're not medically trained, but I was always interested in it. So I was delighted to be able to take students from there.


Uh, and then that was 2018 and they would come through, you know, for regular. A month at a time, they would rotate with me, et cetera. So then they asked me to start teaching a DPC lecture within the family med rotation. So I've been doing that since about early 20, 19. Uh, once every two months I go in on a, have a DPC lecture.


I teach them good answer all the questions, and I've done a few more lectures on different clinical topics as well during the, that day lecturing. So I have a few, you know, so I built that up. And then what happened was when the lockdown happened, uh, telemedicine came to the forefront of the medical schools committees.


They were like, we need to teach telemedicine. We have never really thought about that before. And my name came up as the only faculty member who didn't have to spend hours and hours trying to figure out how to run the practice in March, 2020. It was already happening in my practice. So I was asked to develop a telemedicine curriculum and.


But I put together a proposal on, I decided I would throw in a lot of the other stuff I thought that my students should know. So it ended up that this curriculum that I proposal that I I, it happened to be on the Dean's desk and he called me in May, 2020. And he said, we don't just want you to teach a few students a month on this.


I really like all the things you have to teach about. And can you take the whole third year class in July, 2020? Because we have nowhere to put them because the hospitals are not open yet and they are supposed to be going out in the rotations and we can't do anything. So could you develop this curriculum to teach the whole class 200 students for the whole month?


So I happened to not to be going to Ireland that year because of the pandemic. And I was like, okay, never, I never challenge you. Challenge me. I will rise to the challenge. So, that course was. Th that was probably closer to Casey's fire hose. Let's put it that way. 12 hours a day four, I think I started preparing because of the way that it all worked about four, three to four weeks prior to starting teaching.


And there was this forum one week modules and I was still building module three and four when I started teaching modules module one. So it was busy, but you know, I, it was fulfilling because it was all the stuff I wanted to teach. So our modules the first one is all on telemedicine, history of telemedicine and how to set yourself up, get the lighting, all this stuff.


Hi, to take different cases. Like we do cases throughout the whole four weeks. On we, we, we switched them to just learning about clinical medicine, but how would you approach this if you're on a video with the patient? So one of the ones we did last week was shoulder pain and I usually wear a tank top on.


Show me how to hide. They would tell the patient to examine their shoulder, what they could and could not do on a telemedicine visit. And then the second one is like the meat of what we are all in DPC for. And it's called the health care system on beyond okay. American healthcare system and beyond. So we teach them the history of the healthcare system, Obamacare and all insurance billing, coding, uh mid-level differences since Obamacare on DPC.


And then the third one we can just take, uh, we take a step back from the heavy one, which I was going module two. We're starting that next week with the students. I always call it the heavy heavy one and we go to metabolic health. So a lot of the stuff had been intermittent fasting and the difference between a whole food plant based diet and a low carb high fat diet on what suits each patient, how to deal with obesity, how to talk to the patient about weight on.


Frame it in a way that they can hear et cetera. And then the last one is a coming, coming full circle on talking about starting your own practice, you know, business, pharmacy, running your own pharmacy career goals on high to achieve them. What, what what setting and medicine you can see yourself in. Hi, is that going to affect your career longterm?


So I make them think a little bit about themselves and I make them write a business plan for their future practice. Even if they're going to be a hospitalist or an ICU doc or whatever, they still have to think of something overhead and, and budget and everything. I make them. So, so it's kinda fun.


It's like a mix of different stuff that I did for this class of 200 and that per class, I mean, having to deal with me, I couldn't even see them because we were on WebEx and it was so clunky because there's so many of them on. And there was times, you know, those software that we had tech issues and whatever at the start.


And I just had to be really, self-deprecating like make fun of myself. What's no laughter coming back, I couldn't get any fish. So, so I have to say, I, it went, it went pretty well. The feedback was pretty good. You know, they were all. I'm still pretty disgruntled at the fact they weren't in the hospital. So I, it was probably good to have, you know, this woman with a crazy Irish accent, making fun of herself, at least to, you know, on this course, then we taught, I taught two hours a day, four days a week for four weeks, and then tried to grade as much as I , could and read out stuff.


And I get so many emails and stuff from these poor students, you know, going through a lot of the stuff and even their own insurance issues and all this stuff that we teach them about their own insurance. I make them look up their own insurance. I make them call local hospitals in module two to get the price of a D of a high discount.


They have to get somebody on the phone and get a cost price like that. These kinds of little things that they don't ever hear of and the rotations. So, so then that led to the, the school saying was a good success. Would you do it on an ongoing basis? So we have been doing it for small. Uh, since January, 2021 usually anywhere between four students and I think 16 to 20, which is an absolute breeze NY.


So I do it for the, from September through June and then they take the summer off. And it fits in nicely. Now we don't do four hour or two hours a day. We do two hours a week in person. And most of the rest of it is asynchronous. Some of the videos I did from July, 2020, they have to fall, but we have great discussions and I get to meet some really great, the students are just, it's so awesome to, for me to hear what they have to say, because I keep telling them, you guys like you're going to be taking care of me when I'm old.


Like, I it's important for you to understand where you're going. And this, this is not to depress you about your future. This is to empower you to change the way, the way you think about it and to have power when it comes to making these big decisions about where you're going to work on how you're going to advocate for yourself.


And so, you know, medical students are a very altruistic bunch and idealistic as well. And I was absolutely there in my twenties. And then you start to go through the experiences that you go through from residency and beyond, and you start to get a little hardened and a little frustrated and maybe a little over, or, you know, not enough sleep and not enough time off and, struggles at home, or, you know, just you, you, you sacrifice so much.


And I'm trying to give them, and sometimes making a choice that puts you from. As the medical student or the resident, making sure that you're not taking that contract for the bonus on looking at the T the work workout in the sphere, in that, in, in that in that job first empowering yourself to look ahead.


Cause I think that's, it's very natural. Medical education is so darn long and we sacrifice so much that once you're there and you're starting to make money, just want to get out and work, you want to feel like you're making a difference, but you really have to choose that so much more carefully now than even when we come out of residency.


And I came out in 2008, the contracts are so much tighter and they expect more of you and you have less autonomy in many jobs. So, so we do a lot of the teaching and the med in this. I throw a lot back at the students and make them make them really think about the future we're instead of thinking from rotation to rotation.


So they usually leave the course and, uh, you know, feel a little bit, you know, like that they have more knowledge. And I say, this is just a start. You don't have to remember all this stuff, but maybe when you start to live it in the future years, you're going to come back to this or you're going to come back to me and say, what was that thing you told me?


Or what are you, you know, or you're going to get a lawyer to read your contract. That knows what they're talking about before you signed the contract, or you're going to not stick in the job that you don't love for years and years. And that's one thing I wish I'd had mentors who had, you know, I stayed in the job, my previous job for too long, I should have left it about three to four years prior to I when I did, but I didn't have anybody really to help me understand what was.


So I'm hoping that, you know, the, the teaching that they get, and this will lead them even just to start looking at other things and to start, you know, understanding what's happening and to follow what's happening, you know? So it has gone pretty well. I think that we I've made a difference and I have students then the best part is when students come to my office to rotate after having gone through my virtual course, especially that one class of 200, because they, it was a really tough month for them.


And then to see so many of them coming through my office, they're actually not just graduating. This that's the guy who is in my office right now was in my class in July. And so it is it's very gratifying and some of the mice who came twice to write. So I had two that came twice and, and you know, and, and I have a few who are planning their DPCs after residency night, I'd have, especially out of that class, they're a little further along.


And so it's really it's.


What a gift, you know, not just for, for the students. Absolutely. But just for the listeners as well. I think that's so important to, you know, have those seeds planted at such an early time in your medical students' careers because you're so right. They, all of us, we all should have, and we all deserve, you know, that, that mentorship to help us honor who we are as people, as well as who we are as professionals.


So cannot cannot give


you kudos enough. Well, I think you thank you. And it's, it is nice too, because we have the time to talk to the medicines and the med students who come through my office, they have more time with me. I teach more than probably.


People are saying 25, 30 patients a day on. We flash out really kind of tricky cases together. We look them up together and we will go through them together. So that part has been really nice. But I think one of the things that um, you know, just going back to the fact that I started at APC thinking I was going to do clinical practice all the time.


And then I discovered that I, I always knew I liked teaching because I've taught Irish music since, since I was 16 years old. And my mother is a kindergarten teacher and my mom, my sister is a physics teacher. And so when I started teaching this course, I was like, you know, look at this that, you know, the teacher is coming out on me and I really do enjoy it a lot.


So I've, so, you know, one of my goals would be to bring what I teach to a wider audience. And I haven't figured out how to do that yet. Not just the, the, the students at, at uh, the med school where I teach uh, and, uh, that, you know, I just enjoy it. I've learned a lot on I've educated myself a lot on and got good feedback.


But, I never would have said that five years ago, but I would be teaching a virtual class and, wanting to expand it. I mean, that's the freedom, right? So the freedom to express yourselves, and if we like something, we'd go, you know, we educate ourselves on it or follow that path as well as doing our DPC.


And I think a lot of us are that CA those kinds of people like yourself, you know, running your podcast and, and it's been, that's, that's part of the. Absolutely.


So, so awesome to hear. Now what I want to take a little bit of a digression, because you had also mentioned right before you know, we, we went into this deep dive into how you were mentoring medical students, but I want to ask about your husband, cause you said he's not in medicine.


And when you said, you know, to him that day, like, Hey, I'm going to open up a DPC.


When people are thinking, oh, I totally want to do this, but they're the physician. And then their, their spouse, their partner, their family member is not in medicine.


, I would love to hear for these people, especially any words of wisdom that you might have from conversations you had with your husband or things that you guys have had to think about since you opened?


Yeah. So I remember it took me a while to help them understand what DPC was. He knew I wasn't happy and my old job and he wasn't happy in my old job.


So, so it was, you know, I had gone part-time after residency in order to have that. And do all the stuff that from age zero to six and be able to volunteer at school and grade school and things like that. And, uh, and then, but then the work part was getting so stressful. So, so, you know, I think he I mean my, my goal was to start a DPC practice, try and have it about 50% time.


And and then be more available on the evenings and weekends for my kids, because I was also working like every other Saturday morning and some stuff like that, and kids were getting soccer schedules on Saturdays. So, so the evenings and weekends are much. Uh, at the beginning, I remember by year end, you know, I was working my tail off and he was like, I thought you were supposed to be working less.


You're working more. And I'm like, yeah, I know. But it's like, well, I'm work. I'm happy. Aren't I, you know, and then, and I do remember him at one point saying, so how much money do you make? And I'm like, well, I'm not really sure. And you know, the first couple of years we had, we probably would have, it would have been easier to predict the growth of my income on the practice.


Had I not bought the office one year then, because that brought us backwards. Right. And so that part, he's always about the spreadsheet on the finances and the budget, which is grit because one of us needs to be, you know, on top of that. And and so those have been the questions he's happy to see me happy.


He's very proud of what I've achieved. He's, he's pretty envious. I think of the job satisfaction part, you know, that helping people. He's mad at a bunch of my patients along the way who just, you know, tell him, tell him great things, et cetera. So I actually, my oldest daughter started working in the office, I think was it three summers ago as a freshmen summer doing, you know, Paula as her, her manager.


And she'd be doing like SCUP work as we would call it. And she went for a 360 on, on mom being cool, like to see the patients that actually come out of the office and I made them feel better. And they told her, you know, they were so happy to meet her. And she and I is considering medicine. I think because of that experience in my office and I would never have thought that that would happen.


So my husband is very, very glad that I'm doing what I'm doing, because I think that, you know, I have a much more routine NY. Home. I try not to do work at home at nighttime. I re I'm I we're so busy now with all the kids stuff that I don't know I would ever fit it in really. And so, but for the first couple of years, I probably was bringing work home just because I was growing and trying to grow it, et cetera.


And then we are at the point now where my income is more than I used to make at my old job, but it took a while. So he was very supportive way. The first couple of years, we definitely tightened our belts. And you know, we took a personal loan to, to supplement the mortgage done payment, et cetera, which I am still paying Carra direct care is still paying off to us.


But that was, you know, that's the sign of a good spice, right? They let you follow your dreams and they support you. And so I've tried very hard at, and it is a juggle. I do try hard then to, to keep up my end of the. You know that it would be better for the family. And in general, I do think my kids have more time with me because I started this practice.


Uh, sometimes EPC gets in the way because we are on call and things like that, but it's not that often. And so I'm very, I try to be very intentional about putting the computer away when needs be and spending time with them, weekends are absolutely glorious, like compared to where we used to be. You know, they're just so much better.


I mean, I barely think about work on the weekends. Sometimes it's here and there. I got a call from a patient, but it's so different to what, the way it was. And I could not comment. Uh, you know, I, as I said, I served my DPC when my youngest started full day school. So he was going into first grade. He's not in fifth grade and my oldest is a senior.


My second is a freshmen and my third is a seventh. So if you know, so it's busier now than it was when my kids were you're your age, it evenings, especially, you know, trying to get people to get their homework done and not, you know, I'm trying to get Rita like, just like keeping on them for stuff on then supporting their own.


There's a lot of questions about life and teenage years and processing through social events and things like that. So, so it is and then just the logistics were like pretty much, you know, or if I show first, so just getting people from a to B and being. Uh, events managers and stuff. So I'm really, really grateful that we did it this way.


I'm sure my husband may have a different take on it sometimes, but usually when I'm not paying attention to the family or the highest or whatever it is, it's because I'm doing something because I want to do it, you know, it's enjoyable and it's exciting. It's not because I'm trying to catch up on the charts and the portal messages and the stuff on the, you know, then the, on the training that you have to do for coding and billing and things that are like the, so I do try, I have my, my progression towards, the DPC that I want to have eventually on just the different things that I want to add in my career has been slower than it would be had I not got four children and a husband, but I think that's very normal.


I have to put my life before. On my work second on this job does allow me to do that and I choose the speed at which I embrace the work site. So, so, you know, one thing I did do when I joined the I'm not on the board of the DPCs Alliance, the advisory board, I think it was voted in January, 2021.


But to take that nominate to accept that nomination was difficult because I didn't want it to come in the way come in between, you know, with the family life. I was concerned, it might take too much time, but when my husband was very supportive and at that time, you know, in the winter of 2021, we still were like, we couldn't go anywhere.


And there was a lot of things. So, so that to me was a shining light in my month where I would get to have a board meeting with a bunch of like-minded people on time, some camaraderie, et cetera. So it has, it has definitely been a balanced, , I I've enjoyed it, but I have to be careful that I don't take on other more other things.


That could just tip me over the edge as regards to many work things and not enough family time. So that's always a balance for me because I do enjoy it too. But these times that, you know, we spend raising our kids will never regret and they'll be gone. My oldest is heading off to college soon. So a few more years I'll be saying, oh, where is everybody?


Yeah.


So, so true. And for, for those of us who are listening or who, , recall the days of having children, the quote that I heard off of my love, every mug that came with with my kids play kit was the days are long.


The years are short. Somebody said that to me this week with teenagers, I'll just tell you that, that stuff, there is a sweet spot Mariel. Babies are really time-intensive and then you've got some of those grade school years are beautiful.


That's like beautiful childhood parenting family stuff. And then the teenage stuff hits on. It becomes more intensive again. But you know, at that point, I think it's harder because as I said to somebody last week with teenage anx stuff going on there, they're closer to where you are. You're not always sure you're giving them the right advice because maybe you don't know, you know, maybe they might know a little better, so they're closer to adulthood.


So you're always like, you know, okay, am I helping you form good adult opinions? Or am I giving you my, you know, old adult opinions? You know? So, but it is very gratifying. Uh, teenage, I think teenage parenthood parenting is pretty awesome. It's intensive, but it's awesome. My kids are turning out to be pretty good people.


So I'm talking about that. That's


awesome. And when, when we talk about kids, I definitely have to include here the fact that you, you're teaching kids right now. You've been teaching kids since you were 16 music, but you're, you're teaching him in your own clinic. And you've been able to continue playing.


Irish music. And , you, you've clearly highlighted how this job, how you choosing to do DPC has allowed you to have balance in your life, but in terms of the Irish music, I would love just to hear it, just to have you share about, you know, your history with Irish music and what that means to, to play in an Irish band.


Okay. So, well, I just wanted to say it for anybody who's not watching, but just listening. So mayor Mariel pulled up a picture of an Irish pub. So that's her black rind for, for today. I've played music in that pub. I mean, those chairs look familiar. So, you know, I, music came first and medicine came later.


So I, I was, my, my parents were. Particularly, they weren't into Irish music, but my, we fell into it. My older siblings got some instruments for, for Christmas one year. There was Irish music lessons, so they, they started, I followed on, we become like we had an Irish bond with my family from the time I was 12 until I think my, uh, my sister and her husband just disbanded at about five or six years ago.


So I was with them for 10 years of playing gigs. That was, I made more money playing Irish music than I ever did waitressing or anything else. It's good money too. So it's much nicer to play music than have to be, you know, schlepping dishes and stuff like that. So it was always. As well as fun, but it was more, it was, it just is a it's very social.


So we would go to pubs to play with play in concerts would play at weddings funerals. There are competitions, there are dances. And there would be you know, just general weekend things where people would get together and pumps actually, there's one going on this weekend that we would love to be at.


Our friends are organizing. And it's literally, they just put, they mixed different set session musicians in different pubs. All weekends, you get a row, you get a schedule and you're going to play with this person. And then you go and play with this person. Super fun. You get to, you know, you just sit down and you play on it's, it's really a very social thing.


And so my husband grew up doing that here as well with the last of the social and more of the, just the music, uh, in that he didn't have many people his age. So he went to Ireland. To play. And that's where we met. He was in a class with my brother when he was 14 at a summer school. I was 11 when I met him and he kept coming back in his teenage years and early twenties.


And then eventually we reconnected in our mid twenties, but we always have had our social life is revolves around music. So, I would love to move to California, but there's not enough Irish music there. I don't think I will. I landed in a good city for Irish music. Chicago was full of it. Uh, and uh, I feel quite at home here.


There's some great musicians. I'm very lucky that we are surrounded by music. And so that is definitely music and medicine have always competed for my heart and for my time. And so it was really difficult in med school to play a lot of music, but I managed. I'm honest to do it on the summers and things like that.


And then when I got this opportunity, right out of internship in Ireland to go play with an Irish band full full-time, it was a good time. And it was like a fork in my, in my training. And I said, yes, please. So I did for three years, I re I recorded. That's the one that's LinkedIn, I think at the end of the bio there's.


That was one in my twenties. When I looked young I recorded and played and toured in Europe and states Canada and stuff like that in between my art or tours, I would I would Moonlight. So that actually was the greatest. I, I look back and I'm like, that set me up for DPC, lots of different scenarios.


I learned how to be my own boss. At that point, I had my own schedule on, I took work when I was at home and I went off for four weeks when I was, you know, when I was playing with. And eventually I knew it wasn't going to be forever because I was, I had my training and it didn't pay the rent. So it was more fun than, than financially rewarding, but it was, I've never regretted those three years.


It was all my, uh, you know, mentors on peers in Irish medicine just were like, you're doing what, you know, but I feel like the training I got by just taking moonlighting, lighting jobs all over the place in different scenarios. That was very valuable too. So, so then my husband and I, when I moved over here and I said, I spent two and a half years getting you assemblies and experienced and stuff.


He went into MBA school. Well, during those times. So we were really poor on the only source of income we had was teaching music and playing gigs. And so we took anything we could get on St. Patrick's day around here, you play from 10:00 AM til 1:00 AM, and you make more money and not time and not one day than you do in like three months for music.


So we took every gig we could. And, uh, and so we kept teaching. We didn't do as many gigs once I started residency. My first daughter. And then I, you know, shortly thereafter had more babies, but we did keep teaching for a long time. On, we taught we on and off, we've taken a couple of years off here and there, but most of the time now we teach PE so that our kids will have peers to play with because the social part of Irish music is what gets kids to practice the performance part.


The fun part in the pub, sit, having a session with the, with their friends next weekend. Our next month, we are going to our first, what we call flaw, which is an Irish word on is a competition for. And we have one in the Midwest and we are going to that. We stay in a hotel for the weekend. The kids will play in competitions.


Uh, we are going to plan a car in a trio with my daughter, and we always have a senior Kelly Bond, which is a group of 10 of us that we do. It's loads of fun. In fact, the text just went out today and we do it for the fun and this year we're actually going to get to go to the final that's the qualifier, but we're going to the final in August and Ireland to, for the first time for me in like 10 years.


Wow. So that's the fun part of my, my life and because my husband and I met through Irish music and it's still is the most favorite thing we do. We have tried to pass it onto our kids, and that's the big reason of still teaching because my two youngest kids are in the grip class that I take. Uh, there are 13 and 11 on, so their peers are learning with them on, we just ordinary organized a bunch of St Patrick's day gigs, where they went and played for the school we played for the senior luncheon on.


They just loved it on the seniors. Of course loved it. And that's the stuff that that's the stuff life is made of, you know, it's just, we, it, it gives me, it's just like medicine. It's like helping a patient. Tying music for people is, is just such a gift that we have. And we're trying to let our kids have that gift too.


So it's sometimes hard to fit it all in, but we have Monash thus far to make.


Amazing. So as we closed, Dr. Ryan, can you please share any valuable resources that you've found on your life journey and your DPC journey that others should know about as they're exploring how to make their life balanced, uh, while thinking about DPC?


Yeah, so I would say there's a few different things to say here. Number one is as a teacher of medical students and residents, and I know you have a lot of both who listened to your to your podcast start early and keep thinking about it. Even if you're in a busy rotation, maybe if you get a lighter rotation, start, start thinking, dreaming, start dreaming, uh, on educating yourself.


And maybe you won't do it for five, 10 years, but at least, you know, you know, you'll know how to do it when you do make connections. Uh, social media for sure. Uh, Facebook, Instagram and Twitter are great places to, to make connections with DPC follow DPC docs on those social medias. And you know, join what grips that you can chat, chat, grips online, et cetera.


I feel like that was where I learned a lot of what I needed to know on unmet. The people that I needed more from that gave me their time. That's how I connected with them less, you know, to message them through social media.


One of the big things I think for me was I didn't, I didn't know how to run a business. So I joined the business association and I, I met some really cool people that weren't doctors or DPC doctors that have stayed friends and some of them have become patients. And I've learned a lot from that on, I feel like I'm still learning.


I still feel like I'm very much. A newcomer when it comes to business, I feel like I've, I started so fast that I'm, I'm still learning. I'm trying to try to streamline it for sure. And then, uh, you know, DPC Alliance has built a bunch of, resources. We, you know, that's part of, that's part of my job, the job description with the board, I'm actually currently building a a mastermind handbook.


So for, for people who have, who have gone to a mastermind or want to go to a mastermind or wanting to host a mastermind, it's what I'm building as a host handbook because I hosted my first mastermind in October of last year, I'm doing my second DPC mastermind in the grand jury as well, this October, but I, I wanted to have it all in one.


All the resources for that. So, so DPC Alliance has a bunch for new docs on beyond, and then, you know, keep, keep up with the social media and reach out to somebody if you've got any DPC docs close to you. That personal connection, I think is the most important. Although the only one I did have at the time was Dr.


Sheetal and she was, she gave me freely off her time, but we have a lot more, I, and we're trying to, you know, stay in touch the camaraderie and the DPC community, I think is what makes all the grind of the business running, et cetera, worth it. It's, it's so much so nice to be free and to have our freedom and control over our own destiny and to share that with others.


So that those are the, you know, the, the other, I mean, I just, I think if the, for the people who want to succeed, they will come to me most of the time. They've, they've done a lot of this already. I usually give that feedback to, to people who, you know, call me by DPC. When I see that they've already been reading, et cetera, I think that's the sign of success is that you immerse yourself in it without needing somebody to hold your hand up all every step of the way, because there's so many free, free resources, including your wonderful podcast.


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


Thank you very much. Have a great day.


*Transcript generated by AI so please forgive errors