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Episode 96: Dr. Marty Schulman (He/Him) of Encinitas Personal Care - Encinitas, CA

Direct Primary Care Doctor

Dr. Schulman practices in Encinitas, CA
Dr. Marty Schulman

Dr. Marty Schulman graduated from UC Berkeley in 1981 and the UC San Diego School of Medicine in 1985. He completed his hometown’s Long Beach Memorial Family Medicine Residency Program in 1988. He worked as an associate in a small family medicine practice in Encinitas, California before being hired in 1990 to fill a clinical faculty position at UC San Diego. In addition to teaching students and residents, he became the medical director of his clinic site and later served as the clinical service chief for the division of family medicine. He was one of two family medicine faculty members chosen for the inaugural class of UC San Diego’s Academy of Clinician Scholars. In 2005, Dr. Schulman opened Encinitas Personal Healthcare, Inc. after deciding that he wanted to provide concierge-style medical care at a reasonable cost to patients. To do so, he created a practice model combining low annual fees with low overhead. Opting out of Medicare and having no insurance contracts allowed for him to be paid a reasonable non-discounted fee in full at the time of service. For thirteen years, Dr. Schulman incorporated travel medicine into his solo practice. For the last twelve years, he has served as the medical consultant for a six-bed residential treatment center for eating disorders patients. He has also maintained his relationship with UC San Diego through his hospital medical staff affiliation and work as part of the physician assessment teams at the PACE Program and the Physician Retraining and Reentry Program.



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TRANSCRIPT*



Welcome to the podcast, Dr. Schulman. Great


to be here.


This is such an awesome opportunity for the listeners as well as myself, just because you and I were sharing the stage at the American academy family practice.


Co-sponsored DPC summit in Kansas city. And there, people got a little bit of a taste of your story, but it was very truncated. And so this gives you a different floor, on which to share your story and to be able to share a longer version of your story.


So I wanted to get started with the fact that. Like you said in your opening statement, you've been open in your DPC, for a lot longer than most of us in this community. And so you graduated U C S D school of medicine in 1985. And you've practiced during the time when the insurance, landscape was very different.


And so I wanna ask, when you graduated medical school did you ever want to practice independently or were you employed, after you graduated residency up until you decided to open your, DP.


Well, early on, I had no thought of doing solo practice out of residency in long beach California, I joined a, a practice with three other family medicine docs in Encinitas. I had met my wife during medical school. We went up to long beach for residency. We knew we wanted to come back here to the San Diego area.


And it was a great practice. And I really enjoyed working with the other three docs and all the patients, but at the end of the year, it was, we like you and you like us. And so now it's time to buy into the practice. And that was the heyday of HMO managed care, capitated managed care. And I just didn't feel real confident.


Doing that at that point. And so they allowed me to stay on until I found somewhere else to work. And that somewhere else very quickly turned out to be clinical faculty practice at U C S D where I'd gone to medical school. And so I started there and that was in February of 1990. And uh, did mostly clinical work.


Did some medical student teaching did a lot of resident teaching, attending in the clinic and all that. And then pretty quickly I became the medical director of my site. And at one point I was the clinical service chief for three years. But then after about 10, 12 years, that's when I started thinking about doing something else.


And the thought of going solo probably should have been scarier than the thought of buying into an established practice, but just had to go for it at that time.


I hear. Yeah. And I wanna ask, because you were involved with training others, training the future of family medicine in your case, did you see the residents who were in training and as they graduated, have the same outlook in terms of, I'm going from here residency to an employed physician, or did you see some of those physicians branch out on their.


No, everybody seemed to be joining something established. Very few people were going into solo practice. I, I should mention one of my residency colleagues went into solo practice very near where you um, where you live in practice. And uh, I just couldn't believe it. And that's been, his whole life is in the same place and I envy that.


So, but no, I, I, I haven't seen people with the goal of, yeah. I want to go out on my own from the get go.


Thank you for, for sharing that. And when you mentioned how, you, you probably should have been more scared thinking about opening a solo practice rather than joining a practice or becoming a partner in a practice.


How did you then. To bridge the gap between physician knowledge and business owner knowledge. When the landscape in DPC was even very different because there were very few resources and I mean, you've been open for 17 years going on 18 years, the, the resources are very recent.


I feel in terms of all of the uh, Facebook groups and the resources that people have frequently mentioned on this podcast.


Yeah. We certainly were not trained in business in any way during medical school or residency. So here, here are the resources I had as I was trying to figure out what to do a and part of that has to do with how I came up with my model, the way of being able to provide the type of care that I wanted to provide.


On time visits visits the last 30 to 60 minutes, sometimes quite a bit longer being a available to people 24 7 essentially is to have fewer patients. Right? How do you do that? Either have to charge more or have a lower overhead so that you can have a margin to pay yourself and, live comfortably.


So. On the low overhead side, there was this physician Gordon Moore who was sort of the pioneer that I'm gonna practice all by myself and I'm gonna have one room and I'm gonna take vital signs. I'm gonna do everything in that like that. And I don't know that. I don't recall that he was cash only though.


I think he probably dealt with insurance back then. So, but I'm gonna deal with everything myself and not have to pay anybody and keep my overhead low. And then I don't have to see as many people. And, he eventually hired one assistant I believe and, went from there. So that's one side of it.


And then the other was, that was the fairly early days of concierge medicine. And the, the first guy to do concierge medicine. If I remember correctly was one of the team physicians for the Seattle, Supersonics who $10,000 a year. And he'll see, whenever you want to be seen, if you want him to go to the cardiologist with you, you he'll do that.


So think of how few patients. Need at $10,000 a year. Yeah, yeah. That can be done, but that's sort of a crazy amount. So I, I wanted something in between. So the resource on concierge medicine back then was first it was, it went through a couple of different names. There was the American academy or whatever it was of concierge medicine, and that at one point morphed into the society for innovative medical practice design, or CTI for short


And, and actually I, I attended a conference that they had, it was a weekend conference in Dallas and learned quite a bit. And there was lawyers there and physicians who were already practicing and such, so learned the resources. And so I found a lawyer to help me in with becoming incorporated and helped me with a patient consent form such as it was, it was actually a contract to be part of my practice.


And I call it a membership contract, cuz I considered my patients to be members in the practice mm-hmm so I got that help. I used a real estate person to find space lesson learned don't use the real estate person. Who's also the listing agent. Don't do that. Cuz whose side is that person on?


And did things work? Could things have been better? Probably. I don't know, but that's one lesson have your own person just like when you're dealing with a home sale. So anyway, tho those were the resource resources that I had and took it from there.


Awesome. And on that note, as you're talking about your space, do you own your building or do you rent your building?


I wish I wish I own my building. No. My initial practice was in a dedicated build building mostly with medical practices in it, not exclusively. Lesson number two, as far as face goes, besides having the right representative is don't get too much. I got a thousand square feet, two exam rooms.


Why did I need two exam rooms? If I'm piggybacking one patient an hour after an hour after an hour, why do I need a room to have a second person? And and the plan had been to sublease that space. And I did not do enough of that. And basically in, at the end of that seven year lease in which I put way too much into tenant improvements.


So like. Bye. And I was fortunate to have a colleague who's a chiropractor who had space in my, where I practice now. There's four rooms and in the four rooms there's currently we have two chiropractors, two massage therapists, one acupuncturist, and I have my own room. That's 13 and a half by 12 square feet.


And I do everything in here. I have a, a view of the, I call it the non waiting room. And so I can see when my patients come in, don't have any staff. It's. Go get 'em and we do our thing at that point.


Awesome. And for the listeners, can you please share what's your view like from your


office as we speak?


My, the door to my office is glass, and then I'm looking at the front door, which is also glass. There's a parking lot, one road, railroad tracks, another road. And then the beach, the ocean, I should say. So I'm right across this street from San state beach in Cardiff by the sea, California. There's a few Palm trees that get in the way of my view.


Oh,


very different than Arnold. Oh my goodness. Yeah.


Oh yeah.


Amazing. So now. I love, I love that you've shared, how you developed your model and your space. So I wanna ask when you were opening and you had practiced in the area, did patients from your previous practice come join you or


how did the early days go with regards to onboarding patients to your practice?


Yeah not as, not as much as I had hoped more patients than I, that I thought would come than actually came mm-hmm so that part was a little disappointing.


So, I, I had to grow from without, rather than from, within, in terms of just expecting a whole bunch of folks to come see me now, that being said, some of them took a while and eventually found me some came with me and went away and then they've come back. I mean, it's variable. So I still have a fair number of patients from when I left my faculty practice.


But otherwise it's, it's just grown on its own.


And because, you know, the, this model was very new in terms of it wasn't concierge. It wasn't a typical insurance based clinic. How did you explain your practice to people who were interested and has that explanation or description changed over time?


Well, I mean, you can still call it concierge. I, I don't like that term though, cuz it implies an elitism. So, I call a concierge light for a while. The term was boutique, it was a boutique medical practice. That's sort of gone by the wayside I think. So I, I describe it as having concierge style benefits, basically appointments, same day or the next day they typically start on time were not rushed.


I block out at least half an hour. I usually block out an hour if we finish early. That's great. I'm available 24 7 to my patients. Now it's one thing to do that. If you have 2000 patients or 3000 patients, it's quite another to do it with the volume that I have, which is quite frankly only around 200 patients, I've been able to not have not require a fuller load than that because I've had some other things that have helped supplement.


Supplement my income. So I'm not completely reliant on just seeing patients and, having a, a certain number of memberships or patient memberships to get by. But it, it just makes sense to me that again, after hours, if someone needs you why should they talk to a doctor or a corporate nurse or something like that who doesn't know them?


And I can, can I give one story of where that made a, all the difference in the world? Oh, please. Um, So. At that time, he was in his early seventies, but he looked like he was early fifties. This gentleman who went and to the club every day, played golf in the afternoon, very gregarious.


And I got a call at 1130 at night from his daughter, from the hospital or a hospital in Hong Kong. And he had had a stroke. It turns out he had a vertebral artery dissection that was thrombotic and he lost vision. I think his speech was affected. He locked, lost coordination and it was approaching the, the magic three hour mark.


And the neurologist there in the emergency department or wherever they were offered TPA, but recommended against it because of the, the bleeding risk and basically knowing the patient. I knew that if this patient. Woke up the next morning in that condition and knowing he's gonna be in that condition, the rest of his life, he's not gonna like that.


So it was worth every risk. And so I told the neurologist and, and my patient still quotes me to this day. I, I know my patient give him the TPA and he did. And within hours, his vision came back. His pretty much everything resolved. He's got a, a little residual field, visual field defect, and that's it.


And he's the happiest guy in the world. He, he, he lived long enough to get and survive tongue cancer. And he's still going strong. If that call goes to anybody else, what are they gonna say? They're just gonna defer to the doctor there.


That's incredible. And that really hits, hits home for me. I remember when my dad had a stroke in the Philippines and I flew over there and I needed to get in touch with his fee for service doctor. It was, it was very challenging to try to get in touch with him as well as to get, photocopy pictures that I had taken on my phone of his medical records from the Philippines over there.


So just thinking about your patient and your patient's daughter and the ability to just call you whenever it's a beautiful way to be able to practice medicine for those people. Some are not comfortable with the 24 7 call, but yeah.


For you for that family, I, that just really hits home for me. And I think that that is incredible, that that was their experience because it really changed that family's course, yeah,


absolutely. And, and let me go a little further on that. People are gonna say twenty four seven you're you're on call all the time.


Aren't you have you sleep? So I've been doing this I'm in my 17th year. I've been awakened maybe 10 times. By a phone call in the middle of the night. And I once had this scold the sounds ageist again, because the other patient was ordered. I think she was 80 ish and she had woken up at 1:00 AM with her very first episode of renal colic.


And her husband calls me in the morning to describe what the symptoms are. And I said, oh, sounds like she's having a kidney stone. She should go to the emergency department. Why didn't you call me when it started? Cause I would've given you the exact same information and gone right back to sleep. And they said, well, we didn't wanna wake you.


So I told her for not calling me at 1:00 AM. So no, that's not a burden when I'm on vacation. I'm still, as long as I got wifi or coverage somehow or other I'm available. And before I go, my patients get an MSA email. MSA is a Marty service announcement as opposed to a PSA public service announcement.


Some people call it, call it a Mardi Graham, but they know where I'm gonna be. They know the time zone difference. They know when I'm on an airplane and if I'm gonna be unavailable for more than an hour or two at a time, then I have a, a physician in the community who's available by phone if need be.


But otherwise I got the coverage and the provise with that is typically at the bottom of the MSA. It always says, and if you're really having a problem for which you can't wait to speak to me or so you probably should be going in the emergency room anyway. one more thing about vacation because of that MSA and the patients respect my time and all that, that I hardly ever get bugged while I'm away for a week to 10 days, cuz they know it's my downtime and they're very respectful of that.


When they contact me I'm on and I'm on vacation it's cuz they really need something urgent and I'm all too happy to take care of that because it needs to be taken care of.


Absolutely. And when you mention vacation and if you know, there is a circumstance where you have to have a local physician cover you in terms of your guys' agreement, do you pay that person for, per hour that they're actually taking the calls from the patient?


How do you integrate them into your EMR? How, how does that work? If you have to have someone cover you.


Well, I do the same for. And so we're, it's just, Hey, you're can you put down these dates? Yeah, I'll be available and, and vice versa. So there's, there's no reimbursement or anything. I can't remember the last time that either of us needed to see one of the other's patients.


Anyway, if I had to see one of his patients, I would just do a note in my own EMR and copy it to to my friend. And he would do the same for me. Simple as that.


Thank you for sharing that though, because , I'm sure there's other listeners who are wanting to do the micropractice model and, are, are thinking of those legal questions.


How do I cover, how do I pay them? But I, I love that, your, what you've shared is a, a way to do it without the red tape of administration and that, your patients and that, like you, you're able to even communicate with your friends, like this is what's going on with my patient at this time.


If they call about this, I want to, I wanna prep you for XYZ issue. So that's awesome so now I want to get into. The nitty gritty of your practice and the model. And I wanna start with pricing because your pricing is different in terms of, it's not this is how much per member per month based on age


so can you please share what your pricing model is how your pricing is set up and how's your pricing changed over. ,


It hasn't changed a whole lot, except I, I I've increased things just a little bit over time, but the basic model has been the same.


Since 2005, back then the thought of just doing an annual or excuse me, and a monthly payment, the, the fear was unless you charged in arrears, if you charge it in advance, the fear was looking like a capitated medical plan and here in California, that's, it's the Knox king plan that we were worried about looking like, we we're nothing like that whatsoever, but it wasn't so obvious to people.


So, that's one of the reasons I, I did it the way I did. So it consists of two things. It consists of a practice membership fee and a per visit fee. And. Part of the justification for that is I call it the Congress plan. The practice membership fee is shared equally amongst all my patients. Right.


Everybody pays the same. And how does the Senate work? Every state, whether you're California or Rhode Island gets two senators. So we're all the same there. The house of representatives it's a portioned according to the size. So California has the most number of representatives and there are some states that have one.


And so why should I try and come up with an amount of a, just a standard fee that, well, do I need to lean towards. Minimal users or to the heavy users this way. Everybody pays the same for the membership fee, the heavy users who need to see me six, eight to eight times a year. They're gonna pay more per year.


And those who just wanna have me available just in case and might not see me at all, why should they sort of be supplementing others? So, that's the Congress plan the same in one way and proportional the other way. So my fees now are first family member is $800 per year. Each additional family member is 500.


And I don't charge it for the first three months, so I let people try it out. And then after that most people choose to pay quarterly. So I just send them a quarterly invoice. I have a few people just wanna pay once a year and that's fine. My practice or the office visit fee it used to be based on 200 an hour.


And last year or the year before that, I think I bumped it up to two 50. So generally two 50 for an hour, 125 for half an hour. The very rare quicker visit I'll do ha half again at 62 50. I should probably round that one way or the other. But also different what I do differently. I am cash only.


So my patients are directly contracted with me. Almost everybody has a is part of a PPO plan, so they can submit for service, but what do you need for that? You need details of the visit. So I send them a receipt anyway. So the receipt besides listing my name and, and the practice info and my tax ID number it lists the CPT code for the visit and an I C D nine code or codes for the diagnoses.


And so it'll typically say 99, 21, 4 level four office visit for the following. And I do have the codes for preventive care visits as well. But basically once that's done patient can attach that one page to a claim form and send it to their insurance companies.


You mentioned how most of your patients have a PPO. What are the income demographics of your patients and in terms of adults versus kids, who's in your practice, right?


Age wise, I, I, I, from the beginning, I started with seven and over I did not wanna deal with childhood vaccinations.


And in fact part of my practice originally, one of the ways I supplemented early on was by doing travel medicine, cuz I had done that at U C S D. And so I had a full stock of things, but even so, ages seven and up so as to not have to deal with MMR and some of the other ones from childhood but slowly but surely pharmacies are so available with the vaccinations and accessibility to small practices like mine for yellow fever vaccine went away several years ago and I just said, screw it and gave up doing any vaccinations whatsoever.


I gave up the tr travel medicine practice component. And by the way, that was available to anyone that was not restricted to member patients. So as far as income goes, I have a number of Uber wealthy patients. But I have the vast majority are nowhere near that. They just it's worth it to them to pay extra out of pocket to be able to have the accessibility and the care that they get from


me.


And thank you for sharing that because like you said, when you were starting out the the $10,000 per person per year was not in alignment with what you wanted to bring to your community. So I love that. And I, I love that you have this varied population. So can you talk about your additional fees, so, fees for certain procedures and how are those charged for members versus somebody who's coming for a one off visit?


Well,


I typically don't do one off visits. It's it's not fair to the members for the most part. Although the the exception to, to that is, and this is a part of the, the member services is if aunt Jenny is visiting from out of town and something comes up and she needs to be seen, I'll be happy to see aunt Jenny and there's no membership fee, and it'll just be the regular fee.


For service visits. As far as procedure fees go it's pretty much included. I, I, I generally, even for the most part included EKGs once in a while, I might charge separately for an EKG, but, it was sort of like, well, if it's an hour long visit, okay.


The EKGs included if it's a half an hour visit, but I had to do the EKG. Okay. I'll throw that in. And I think my fee for that was 35 and I finally increased it all the way to 50. So, but I'm trying to remember if I've stopped doing lumps and bumps, you know, skin boxy stuff. There's too many dermatologists around and they're gonna do a way better job than me anyway.


So, I may have charged for those early on. But that's it.


Gotcha. And when you talk about your services, when you talk about your practice size, and you have mentioned that, ideally you have 30, 60 minutes for between patients how have you been able to manage this without staff?


Pretty easy.


Cause you know, I know how to take vital signs. I know I had to learn how to give shots. I actually went through all of medical school and all of residency without every once given a shot. Wow. The very first intermuscular injection I ever gave was in the private practice that I joined out.


Residency. And they had a Saturday morning session, a lot of it was urgent care type of stuff. But as the new guy, I, I had the most frequent ones and there was a woman who had to get her every four weeks Stine injection. And the nurse couldn't do it. I had to do it. So that was my first one.


And then by the way, I, I did start out with the medical assistant. I forgot that part. I had a medical assistant slash receptionist. The first two years problem was after two years, I was paying her more than I was paying myself. And it was time for her to go. So that's when I went Uber solo because I wasn't completely to begin with, but no I can make appointments.


I had to actually rather be in charge of my schedule than anyone else anyway, cuz I can figure out how much time and where is best and all that. So, being solo is just fine. I need to add on to that though. The hardest part of being solo though, was actually keeping the books. And so I think it's been seven years now, maybe eight I finally gave in and I have a friend who's a bookkeeper and I just, she took over and that she's worth every penny that I pay her to do that.


Cause especially if you're incorporated and you have, there's so much more involved, not maybe not so much more there's, there's more involved if you're incorporated than if you're not, but regardless you have a whole lot of. Things to keep track of and just to be able to give it to her, I give her documents every other week.


She, makes sure everything checks out and we're ready to go for taxis.


And I wanna ask a few more details there because when you were doing it before, that seven to eight year mark hit and you hired the bookkeeper, what were some of your biggest pain points in terms of, it sounds like catching up on stuff was a big one.


Yeah. But how did you, how did you try to, to manage it all before you hired your bookkeeper?


The, how, how I ended up managing it most years was as tax season approached. It's like almost going away for the weekend and locking myself in a, in a hotel just to get it done. It's, there's checking accounts that need to be, Checked against the QuickBooks and credit card things that need to go into QuickBooks and all that.


It, it, that was a pain in the, in the behind. So I was happy to give that up.


Well, I, I appreciate that honesty because again, you and myself and everyone who is a physician who chooses DPC, we go into this most of us without some kind of business degree or business training. And, there there's chatter about what do you use zero QuickBooks, a bookkeeper, and everybody does it differently, but I will say that that, that definitely is something that I hope a lot of people will just, take those words and especially about the finances and think about how, how they're planning their own finances or how their finances are working well, or if they could be improved just by hearing your story.


in terms of, scheduling you, you mentioned how you, you like having the control over your schedule, and I completely agree with that. I, I love being able to pivot and to be able to fit people in, especially being a relationship based doctor, we know our patients and we know which ones will take a little bit longer, or which ones have social issues going on, where we might need to do a family visit.


So for you, do you allow your patients to self


schedule? Absolutely not. And I, and I thought about that, but no it's that that's something I don't want to give up control on, but, scheduling is as easy as sending me a text message too. And so sometimes we don't talk. It's just message. Hey, we're due for a visit here or, and it can be an acute or a, a follow up and either way it can be a text message.


Sometimes it's email. Sometimes they call. But no, I, I, I want to have that control and you know what, early on I was always, if someone was scheduled an appointment, I went right into my EMR, but I also kept a, my Google calendar. Right. So duh, just put it in Google, cuz Google's with me everywhere.


Right? The Google calendar. And so I'm making appointments on my cell phone and then. All right. When they show up and it's time for their appointment. Okay. Then I put it in the EMR. There's no reason it needs to be in the EMR in advance. So that was something I took me a surprisingly long time to figure out and, yeah.


Years and years in, there's still things I, I can change and do better. Yeah. But, or easier.


And you have the freedom to do that. So that's incredible. That's


right. I, I just have to speak to the boss and tell him the better way to do it. And he usually listens


by


chance. Are you're a Gemini? No. Oh, yeah.


I joke about that a lot because I am a Gemini and, and so I just wanna ask, but uh, I, I digress um, terms,


do you have your twin?


Is that the


idea? The, the, the, the twin who's the squirly twin who likes the shiny new object and then the twin who's like, remember the consequences is if you choose to do to chase after that squirly shiny object. Yeah. Yeah. So when you talked about. How you wanted to have the waiting room that has no waiting and, and you've designed your schedule so that your patients are getting 30, 60 minute visits.


How many patients do you see typically in a day in person versus how many do you take care of versus over telemedicine?


Actually during, during the peak of the COVID stay at home stuff the lockdown the majority were tele visits. But now I do those very rarely. And I still do an occasional house call.


So most for, in person, my visits per day are anywhere from zero to, usually there's one or two, again, remember I'm, I'm running with 200 patients. And what I learned way back at the beginning was that on average. Around 1% of your patients need to see you every day. So think about that. If you have 200 patients, that's two, if you have 2000 patients, that's why you're seeing 20 to 25 patients a day and, and that's untenable.


So anyway, there's always more to do. And part of the for me, the timing was the two outside activities that to a certain extent sustained my practice. While I was trying to do above and beyond what I was just doing. So the, those two things are one being the medical consultant for a residential treatment center for women with eating disorders.


And I actually got into that when one of my patients who owned a facility said, Hey, our medical consultant is leaving. Would you like to do that? And it's as many as six people at a time and. For those who don't know residential treatment center is it's one level shy of being in hospital. So there's orders that are written and, and now we have an EMR for that, of course and followed by nursing staff and an admission history and physical.


And then instead of daily progress notes, it's weekly visits. And so I worked with that one until it closed. And then another one that's actually part, part of a very large corporation opened up. And the psychiatrist who got hired for that one knew me from the previous one and recommended me.


And I've been doing that since it opened about. Eight years ago, something like that. And so I have to have time in my schedule to do that, but the cool thing about not scheduling way out is the flexibility of, okay, I have a new patient coming in. I gotta go do the admission H and P and oh, here's a block of time.


I can do it cuz I haven't scheduled anyone there or anticipating that it's gonna be there knowing not to put someone in there. So that's one thing. The other thing was for a number of years when I left U C S D full time left the clinical practice, I started working with U C S D's pace program, physician assessment and clinical education, essentially an evaluation, a competency evaluation program, as well as remediation education.


And I worked strictly on the evaluation side of things. And that ended up being a 50% position. For, for me, one of the beautiful things about that was I never had to worry about getting healthcare independently because I maintained it through U C S D even working part-time. And the other beautiful thing about that was I was already, contributing to the pension and that continued.


And so a couple of years ago I decided, well, I'd like to stop working 150% time and just work a hundred percent time. So I, I retired from. And substituted the salary from there, with pension. And again, that supplements that the eating disorder center actually flows through my clinical practice through my corporation, but that supplements my income from the clinical practice as well.


And as you mentioned, how you have your, your practice, your Encinitas personal healthcare practice, but you also have these activities that have supplemented, what advice would you give to other people, especially those who are opening their DPC or looking to start supplementing?


How would you, advise them to think about supplementing Their income in terms of what types of jobs mesh well with DPC in terms of having the time to be able to do your DPC plus something else? Yeah. I would love to hear your, your thoughts on that.


Yeah. I, there's probably other opportunities out there.


I mean, there's, there's centers out there that are residential treatment centers that, that need docs can you do urgent care shifts that, that gets a little dicey. If you're giving up, all your insurance contracts and opting outta Medicare, and then what happens when you go work for someone else?


I don't know, quite frankly how that works, but the beauty of, minimal number of patients and having the flexibility is yeah, you can work your patients around your other things. So I think that's really important. And, and one point I wanna make. Again, I'm at 200 patients. I, I don't think I've ever had more than about two 50 in my panel.


And it's because I've been able to do that cuz I've had the other things. Quite frankly, if, if I didn't have those other things, I'd have to have a bigger panel to earn, earn an adequate income. I'm not, I I'm thinking probably closer to 400 mm-hmm maybe 500. So I never felt the urge to push it.


But you know, if someone had to rely on this solely that they'd have to do a, a better job than I did of actually going out and recruiting more patients.


And so when you were mentioning how you've changed in terms of going from that 150% to a hundred percent working, and you mentioned how you had healthcare through UC San Diego. Do you still have healthcare through UC San Diego or have you had to purchase a different type of plan for you and your family?


So when you retire from the university of California and you've built up a pension, you have a choice when you leave lump sum payment or an monthly annuity two advantages of the monthly annuity besides the fact that if you're gonna have any sort of good longevity at all, you'll actually outlive your lump sum payment.


But the other part, parts of it are, if you take the annuity, you get to continue, you see healthcare coverage, thank you to the taxpayers of the state of California of which I am one, but everyone else is helping me out. So that's a beautiful thing. And my wife is two years older than me. She transitioned into Medicare.


Last year I don't have to choose a Medicare plan. UC chooses it for me, it's just seamless. And so it couldn't be easier than that. The other thing is The annuity, the monthly pension plan. I can not only as have my wife, collect after I'm gone, assuming I go first, but I, we can we were able to pick someone beyond her.


You can pick a third person. And so it sacrifices a little bit of the monthly now, but this is going to someone who's gonna need it in the future. And after we're gone and I couldn't be happier about being able to do that,


that's definitely an incredible opportunity. And, the, I don't know how other universities do it, but especially for those people who are in California who possibly have a UC involvement in the future.


It's definitely good. Good information


to know. Yeah. And, and actually another piece of advice, which I did not, I don't know if I got it early on. I certainly, if I got it, I didn't follow it. But for Folks listening, especially early in practice. And you don't get a pension unless you work for someone else.


Right. That, and so I had the good fortune of getting that, but you do have the opportunity of putting away into whether it's an IRA or a 4 0 1. If you're incorporated, I don't know if you need to be incorporated to create a practice or uh, a 401k or whatever, do that early and often max it out right away.


And you're gonna be really happy when it comes time to retire or perhaps be able to retire early. I had to spend a lot of time catching up later. Just the sooner you can do it, the better just live off less, put it away, watch it grow and have it there waiting for you at the end of the rainbow.


I love that.


And I mean, even for those people who are medical students and residents look into, maxing out a Roth IRA, if you have kids look into those 5 29 S now it's definitely it. These are, that's such Sage advice to think about the future and the future generations. even if you're planning that future generation.


So that's thank you so much for, for mentioning that. And yeah,


I, I, I just thought of something with red hot chili peppers, what's their layer, give it away, give it away, give it away. Now it should be put it away, put it away, put it away now that well, that that's the mantra. I love


that. And as we talk about longevity you know, your impact I wanna ask about the future of your practice.


So . Have you thought about, you know, are you going to recruit somebody to join you as you, plan retirement or do you see, you practicing until you're done? How, how do you envision your practice going into the future?


That's a good question. It's not that many years off. It's probably about a five to seven year horizon.


Just based on a number of things, ideally I'd have someone just sort of come in and take over maybe coed for a while. I'm not sure that we'd have to adjust the space a little bit, cuz someone would have to have his or her own room to operate I think. But no, ideally there'd be a little bit overlap and then just.


Take it away from there. Gosh, how do you value practices these days? I know there's, there's folks out there who do that. How attractive is it to come in and say, well, alright, I'm gonna give you this much money for your book of business or whatever it's called. And here you go. Or do it, obviously do it over time.


I don't think you could ask for lump sum. That would have to be something over time. I'm not sure I wanna do that. I'm not sure. I just don't know. And that's okay. Now you're making me think about stuff but


I love planting those seeds because oh yeah. I, I think about, yeah. Yeah. I think about how Dr.


Thomas bite shared, he was thinking about these things when he brought Dr. Buchanan and Dr. Carpenter into his practice in preparation for his patients to have continuity of care. Yeah. While he was still there and able to help mold the practice still and their way of managing the, the practice itself.


So, yeah, I think that's


great. Yeah. I, I, I would like to have someone take it all. I, I do not want at the end for it to be byebye you're on your own. Go find someone and let me know where to send records. I'd like to have someone come and take over, and that's gonna require me to find someone for them instead of them having to go out and find their own.


But that's how I'd like it to end at that point.


And when we talk about that goal and we look at the landscape of fewer people choosing primary care how do you envision making an impact on the future generations of medical students to encourage people to choose primary care, especially when you can practice like a DPC physician?


Yeah, no, that, that's a really interesting dilemma because there's one side that says, well, Pay us enough and we'll be happy to go into primary care cuz you know, we don't get paid enough, $300,000 a year for a salary job. Okay. I'll do that. But it it's not there yet compared to the others. On the other hand, who wouldn't wanna do a practice like ours, where you're taking care of fewer patients and you have a life and you have an adequate income and you don't, I don't think any of us are doing it for the money.


In terms of, yeah, this is the best way for me to make the most money. We, we wanna be comfortable. The problem is if we said, all right, everybody's gonna just have a panel of four to 600 patients. Well, take your primary care shortage and multiply it by a factor of how many cuz now you need to take care of, let's say 2,400 patients instead of one doc, you need four how's that gonna work?


I, I go off on the insurance aspect of things. Why is, why is insurance money used to pay for primary care? How does that work? It's money into the system. The in insurance company takes its now at least it's capped at 15% from the ACA and then money out to us. What's the added value of that.


Why is insurance being used for routine stuff? So in other words, it's prepaid healthcare, it's not insurance. The what's the example. You don't use your auto insurance to pay for tires for a new battery for an oil change, routine maintenance and your home insurance is there in case your house burns down or something drastic happens, it's not to maintain it, right.


So why should that be used for primary care? Because everybody needs it. Why should it pay for something that everyone needs insurance should be for something catastrophic? It should be really bankruptcy. Insurance is what I like to say. So take all that money. And, from the insurance system, pay us a fair amount to take care of a reasonable number of patients.


Gets to what happens to insurance premiums. They go way down, right? Because it's only for the catastrophic stuff. And of course there has to be a safety net for those who can't even afford $1 to, do something primary care wise, but other, and what else happens when you do that? When it's all cash pay, it's called competition.


And it's competition between physicians. If it's competition at the labs and imaging centers and everywhere else, guess who's gonna have to publish all their prices so that things are obvious us doctors. Sure. But everybody else too, and maybe even competition for pharmaceuticals, but a novel idea. .


and so many listeners I'm sure are just nodding their heads in agreement with, with what you've shared. So now I wanna ask closing, are there any other words of advice that you would give to people no matter where they are in their DPC journey,


Talk to others who are doing it, you know, the Facebook pages of the different there's different DPC ones.


We have our own for California. Woohoo. Everybody's got so much to offer and so take advantage of that. I I'm gonna give an analogy from, so I started my practice October of 2005. And in January I saw in the, the weekly coast news flyer for Encinitas business exchange. It's a networking group.


Hmm, maybe I can grow my practice that way. And so I, I went to the next meeting and I've been a member ever since I've worked my way up. I, I was president for one year. The, I could count the number of people who be become patients in my practice because of that membership. Mm-hmm , I don't even need all of two hands.


Okay. But guess what? I've, people have the plumbers for our house and the electorate and all that. So I've met great people to do stuff for that, but one of the other members pointed out and, and it became really obvious when he said it. He, he said, I have learned so much from each and every one of you.


And it really is. We're not business people by nature. And to be part of a networking group where. You, you just, you really do. I do learn something every week from everybody else. And so get knowledge from not necessarily the places you'd think you'd get it and be open to things.


Love that. Thank you so much, Dr.


Shelman for joining us today.


It has been my pleasure.




*Transcript generated by AI, so please forgive errors.


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