Every Hill I Will Die On: My Top 5 Hot Takes for Future DPC Docs

In this episode I’m sharing my top five (somewhat) controversial opinions starting a successful direct care practice, including

• The two invaluable things I spend $$$ on that everyone told me not to
• Why I think copied & pasted legal docs are a bad idea
• My thoughts on choosing an appropriate price
• The types of practices I try not to associate myself with
• A tip that most docs are nervous to take but creates magic

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Connect with me on IG @soniasinghMD
Email me at sonia@micropracticemama.com
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Transcript

Speaker 0:01

Hey doctors. You're listening to the Micropractice Mama Podcast, a podcast for women physicians who are striving to practice primary care sustainably and creatively with autonomy, authenticity, and joy. I'm your host, Sonya Singh, internist, PCP, and proud mother of two human babies, one for a baby and one life-changing Micropractice. I wanna empower you to push past whatever is holding you back and make the leap to launching a practice that aligns with your values and priorities, and finally allows you to take care of your patients, your family, and yourself in the ways that you want and deserve. Are you ready to make the leap? Let's do it. Hi doctors. All right, so this is the first real. Episode of season three of the Micropractice Moment podcast. And this episode is titled Every Hill That I Will Die On. And the inspiration from this episode is that there are a lot of times when I'm talking about something that I feel strongly about and I say this is a hill I'm willing to die on. It's usually things that I think I am uniquely passionate about that maybe other big voices in DPC are not as passionate about or disagree with. And I thought, why don't I make an episode where I just talk about all of those things?'cause there's several things that I have said that about. And so I thought, let me put them all in one episode. So if you've been following me for a while or have done my course, or, have been following, getting the newsletter for a while, some of these are gonna sound repetitive to you because they are things that I do talk about a lot and I feel strongly about. If, if you have been following for a while, hopefully this is just reinforcement or like a nice reminder of. Some of those ideas. But if you're new to the Micropractice mama world and you haven't, listened to a lot of my other content, this is a really nice summary episode that I think encapsulates my flavor of DPC and Micropractice and what my style is in this arena because I wanna preface this all by saying. I don't think there's only one way to do this, so the things I'm about to share here that I obviously feel very strongly about I don't think it's my way or the highway or this is the only way to do it. I fully acknowledge that there's a lot of people who don't do these things and are perfectly successful. But these are things that, I encourage the people that I'm mentoring to do because I have seen them work for me, and I also talk about them a lot because a lot of these, like I said, a lot of people in the DPC world don't. Agree with me on these things. And I just think the alternative opinion deserves, deserves a little attention. I feel like every time I say any of these things in a Facebook group, there's always one or two commenters that are just like I didn't do that, and I'm doing fine. And I get it. I don't deny that you were doing fine. These are just things that I really value and think are important and encourage people in my course and other people that I'm mentoring to strongly consider. Anyway. Without further ado, let's talk about, I have 1, 2, 3, 4. I have five things, five hills that I will die on. Okay. So the first one, and you've heard me talk about this before, is to get a lawyer, to get a lawyer to do your documents, especially all of your startup stuff, your membership agreement, your code of conduct if you decide to have one. I have a list of all of the legal documents that I use in my practice, not the actual text of the documents, but. What they are and what their purpose is. I have that on the Micropractice Mom website and you can sign up to get that for free if you want. But basically I think there's this culture in DPC generally of DIYing everything. It's just bootstrap it all, do it yourself. Don't pay someone else to do stuff. There's no need to. You can do it on your own. And I. I actually appreciate the root of that sentiment. I think that kind of attitude was totally necessary for DPC to exist in the first place and to, have even, started as a movement because I think there's this learned helplessness we get through medical school and training where we just feel as though we need to rely, or at least my generation of doctors, that we need to rely on this. Huge administrative machinery to do our jobs. And the reality is you don't, you don't need anybody else to do a referral or to place an order or send a prescription. Like you can do all that and you can start a business. And I think goes overboard when we're talking about these legal documents because Yeah, I wanna convince doctors that, look, you're a perfectly intelligent, hardworking, ambitious person. You can start a business People who are on paper less qualified than us, do it all the time, do it successfully on a regular basis. So you can do that. Now, can you write a appropriately detailed thorough legal document? That's. A kind of a different thing. The analogy I give is how do you feel when patients do their own research about some treatment or protocol or how to manage their hypertension or whatever and they come to you and they say yeah, I've done my own research, I've come up with this plan and I'm gonna do X, Y, and z. had this experience all the time with tech workers in the Bay Area, they're very smart people and they have so much data and they do so much research and then sometimes they still arrive at the wrong conclusion. Because they don't have four years of medical school and three years of residency and 10 years of clinical experience, they. They just don't have the same, foundation of knowledge and experience that you have. When patients come to us doing their own research, you know how you feel about that. So if you were to ask a lawyer or tell a lawyer, I think I'm just gonna use this template, or I'm gonna copy and paste my friends, membership agreement. They have a DPC, it's like mine. I'm just gonna do that. They would say, you're a fool. They would be like, absolutely. You should not do that. This is a terrible idea. And then you may respond with yeah, but they're a lawyer and that's how they make money. But that's exactly how, patients think when they're thinking about, whether they should just, treat themselves on their own or whether they should go see a doctor is of course the doctor's gonna tell me to take the medication'cause the doctor wants to make money. Or of course the doctor's gonna tell me that I need to see them for this'cause the doctor wants to make money. And you and I know that's not, why we make the recommendations that we make, anyway, I just think it does not make sense to try to DIY something that is that foundational to your business and that is that important. And remember that in DPC and especially in Micropractice, you are on your own. There is no legal department that's gonna come save you. There's no ethics committee that's gonna talk over what is the right decision in some strange situation you are making all these decisions, and oftentimes you really don't even have anyone to bounce these things off of. And I think, having somebody to help you anticipate all of the problems and issues that may arise, which is what I've found. Every lawyer that I've worked with has helped me do that. Of thinking, even as far as with Micropractice Mama, thinking about situations that may occur and how we want to deal with them, and just deciding that and putting it in writing beforehand so you're not having to make those decisions later on. And I think a lot of people will say, oh, I just copied and pasted it. Been fine. I've been in practice for 10 years. It's been fine. Great. Good for you. I'm very happy for you that it has been fine. But that is not guaranteed. And I'm partially just anxious and risk averse, but knowing that I've spent time and, I've had an expert guide me on what is exactly in those agreements and how I've phrased it, and my contingency plans for various situations. Makes me feel more confident. it makes me feel more confident in situations where I've had to terminate somebody from the practice. And having at least a protocol to do that. Anyway, I think that you, this is a one-time expense. Yes. It's expensive. It's painful when you're starting up and you're already spending money on a lot of things to now, give a few grand to a lawyer, but. It's not a recurring expense, you're gonna do it one time. And these are hopefully documents that you're gonna use for 10 15. Who knows, 20 years, who knows when. I haven't had to update mine really quite yet, but at some point I probably will have to update them. But these are documents you're gonna use for years and years for so many patients, and so I, I just think it's worth it to have those be of the best quality and to have those professionally reviewed and. Personalized for you and exactly what you do. When I did my documents with my attorney, who's the one I worked with for startup has done a lot of DPCs and even though she's done a ton of DPCs, she edited a lot of things specifically for me because all of the people she had previously worked with were family medicine. I am internal medicine, so the, I don't see children. I actually don't give vaccines in my clinic. I have people get those at. Pharmacies. And then a lot of the people she works with do home visits. I was willing to do home visits, but didn't wanna guarantee them. And, I had all of these kind of unique circumstances that I wanted to work into the documents and she helped me do that. And so I just think it's, it's worth it. It's worth a little bit of extra money. And when you think about the grand scheme of things, I don't know, five grand, seven grand. It's not ultimately in the grand scheme of things, not a huge expense. When you think about how much you're hoping to earn and for how many years. Okay? So that's my rant on getting a lawyer. All right, next. Branding matters. So again, I know, I feel like I sound like a broken record. I talk about this all the time. I think there's a ton of doctors out there, probably the vast majority, who just think, yeah, you just pay someone on Fiverr to give you a logo and some colors and you just run with it. Or your friend makes it or your wife makes it, or you make it on Canva, throw something together and move on. That, that was definitely the attitude when I was starting my practice and, that's the message I was getting from all the DPC forums and the people I had spoken to, no one could, I think, even wrap their head around the idea of spending a couple grand just on branding. And I did that. And I feel now that I'm seeing more and more people considering that at least, and I think there's this idea that it's just making stuff pretty, like you're just paying someone to make something more aesthetically pleasing and what's the point of that? Like I think a lot of doctors will say the patient doesn't come to you'cause they like your logo. Like patient doesn't come to you'cause you have a nice office, patient doesn't come to you. They come to you because of your expertise and who you are. That's, I think that's a little naive. They truly do not know what kind of doctor you are until they've come to see you. So you are having to convince them and communicate a lot about yourself and your value, and your mission, and your philosophy, and your general approach, and your demeanor and your voice and your tone. You are having to communicate a lot of stuff. Before they ever have the opportunity to have any idea what kind of doctor you are before they set foot in your office. And we know from marketing research, big corporations are not stupid. They're spending a lot of money on marketing and branding because it works and it's really important. And, people make quick judgements about. Companies and practices and people, within seconds of looking at their website. So if you have just not put a lot of thought into that and you've thrown it together and di again, DIYed it without really having any kind of expertise in that arena, there's a good chance that you've just lost an opportunity to communicate a lot of stuff to the potential patient. I think branding, and I've sent this graphic out so many times, it's all over my course. There's a nice little graphic of an iceberg where the top is like visuals, colors, and logos. That's just the tip that's showing over the surface. And then underneath it's mission, values, philosophy, voice. All of that stuff is should be communicated by the visuals, the colors, the logo. And I just think a lot of people just have the top of the iceberg and it's not even connected to the bottom of the iceberg. And they're not aware that there is a connection. And so I think to do branding effectively, it has to actually be thoughtful and strategic. It cannot just be. Like, I think this is why it doesn't quite work to just maybe buy a pre-made brand on Etsy because you have to make sure that whatever that pre-made brand is aligned with exactly the what, the bottom of the iceberg is for your practice. And if you're just picking something that in your mind looks pretty to you it may not actually connect that way. So for me, working with an actual brand designer is what helped me figure out what. Top part of the iceberg actually reflected the bottom part of the iceberg or what? What connected, because I had a vision for what I wanted the logo to be, and I took a few passes at it myself, and I described what that vision was to my brand designer, and she delivered exactly what I described, but. In the meantime, she had also had me do this very long brand questionnaire that had me think about who is this patient that I'm speaking to? What do they like, what are they drawn to? What are brands that they are familiar with and evoke positive feelings for them. What are they looking for? Who exactly is that person? And when I really thought about who that person was, I realized that. The initial, vision I had pitched to her was off the mark. It was, honestly it was too young. Like it was something that may be attractive to someone in their early twenties. But that's not actually who my main. patient population is. And so it was painful, but I had to be like, I'm sorry, we have to revise this. Because I just realized there was this total disconnect. And I think if I had gone with that initial vision, which I liked and was cute, and it was, it looked aesthetically pleasing, it was nice. I don't think it would've been nearly as successful and effective in communicating what I was offering and in attracting people who are in my ideal demographic. Again, I think we get very cost conscious about this and doctors tend to be very scared to spend money on something that feels not so tangible or just feels okay, I'm just getting a few JPEGs. What is this? Is this all I get for my thousands of dollars? But again, branding is a one-time expense. It's something, you do hopefully once and if you wanna do it again, you can do a rebrand. But once you've got those files, the possibilities are endless. You can put them on so many things going forward, you can. Make your own letterhead and you can make it there's, once you've got the fundamental branding materials, that's the gift that keeps on giving. You can use it for years and years, and I really think you can tell when someone has paid for quality branding. I can tell right away people often ask me to review websites and stuff, and it's obvious, instantly obvious when someone has done their own branding versus had a professional do it I think you know that alone, even if the patient can't put their finger on it, when they see that level of professionalism and quality makes them think this person put time and thought and money into this. this is really well done and that. That means something to them versus, oh, this person obviously put this together over the weekend. Or their cousin did, or their friend did, or, it's all AI generated and it's just a generic Squarespace template. So anyway, branding matters. Alright, next price appropriately. This is a very I don't know what to say. Hot. It's a hot button topic in DPC because I think there's a segment of DPC docs that feels that, you must be doing the purest version of DPC to even call yourself A DPC. And if you're pricing is, too high, or the panel's too small, whatever, then you're just, you're concierge and you're calling yourself DPC. To me, the definition of traditional concierge is that. Your billing insurance and you're also charging a retainer. So I bristle at the idea that I am not A DPC I could do the other model. And the reason I choose DPC is for the price transparency mainly. And so I, when I entered the DPC world, I felt the culture was very much to price low. The average we know from that, actuaries report that I reference all the time in their market analysis, the average price was 70, around$75 per month per patient. I am priced significantly higher than that. And that is because I feel that when I add up the number of hours that I spend with people and I compare it to other services in the marketplace, and I think about. What my capacity to care, what size panel I can care for, and what income I would like to make at the end of the year. The price that I have feels appropriate and that price is much higher than that DPC average now. That's not to say that nobody should be charging that price or that price is too low. I think if you run your clinic in a way where it is a little bit more, 15 to 30 minute visits and you have a larger panel and you are not answering messages, at 7:00 PM or on the weekend, then. You can charge a lower price. I can tell you right now that if I charge 75, I would have hundreds of patients right now and I would be burned out. But that is also because I practice in a different way that I think is just you. You can call me slow. You can. I don't know. You can call me inefficient. I just think I take a lot of time, like I want a lot of history from my patients. I literally go back to their childhood and talk about medical and psychosocial development starting then, because a lot of my patients have psychosomatic issues, chronic pain, health, anxiety, and so much of that is rooted in their early life experiences. I'm going way back. I try to review all of the history and records I can get my hands on before the visit. I spend usually 30 to 40 minutes after the visit digesting the information. Even if I have an AI note writer. I try to sit and digest the information and write out in my own words, a kind of a summary of that first visit and a plan for them. For all subsequent visits, I basically use ai. But when I just add up all the hours and expertise that I'm pouring into these patients, I just think that my price is fair. I honestly think it's still a good deal. And I always tell people, look, if I save you one er visit in the year, that pretty much covers the entire fee. there is a concierge practice here in Houston. That charges$20,000 per member, per year, 20,000. And I've had a handful of people leave that practice and come to mind, and they think I'm a fool. They're just like, why are you not charging more? And I am, I'm very committed to staying at this price. I actually don't really wanna go any higher. I think this price. Keeps me accessible to more people. And I could go higher in that. The demand is there, but I think you start attracting then a different type of patient that is looking for maybe a different thing. And is maybe used to that$20,000 a year concierge type environment, which honestly does a lot of stupid, not indicated testing and, nonsense supplements and just. Generally a bunch of nonsense. And I just, I, it's energetically costly when you start attracting people who expect that nonsense and think that's normal and what you get when you join a, a membership based practice. So anyway, I'm good with my price. I feel very confident about it. I'm not gonna go up on it, but I feel good about where it is and I think you should feel. Just as comfortable, pricing higher than that DPC average and not feeling bad about it. I think when we assume that the price another doctor is using, which with a completely different practice style, who attracts a completely different patient population and who practices in totally different environment with different demands, we run the risk of, pricing inappropriately and burning ourselves out. Anyway, price appropriately. That is one of the hills I will die on. And I think a lot, especially of women in DPC price too low. Okay, next evidence-based medicine or bust. So I am what's the right word? I am very stringent about my support of practices that only do evidence-based medicine I don't even wanna name specific things'cause then people are gonna message me and be like, but have you seen this study? See, there's data for it. So I, I don't wanna get into the specifics of where I draw the line on evidence-based medicine, but I just think in general as a movement. It would greatly benefit us, and it would help us to make DPC mainstream if the vast majority of DPC doctors are doing evidence-based medicine because the cash-based world already has a reputation for. Selling snake oil and, doing things that are not indicated. And like I said, these crazy concierge practices that just do stress tests on everyone and order, 500 micronutrient profiles on everyone like that is already the reputation of the cash-based world. And if we get lumped in with those, then I don't think DPC will ever feel like it's a legitimate. Or reasonable option for people who are outside of the top 1% or people who have just a ton of disposable income. And the reality is it should be, especially with what those averages are that I just mentioned, a lot of DPCs are within reach for people and they could be an economical choice for a ton of people because you know the, if, go back and listen to the episode, DPC is Not what you think, or there's another episode I did called primary, why Primary Care is Better Without Insurance, if you wanna delve deeper into this topic. Or there's also, I did an episode on evidence-based medicine in a cash-based world. All of those are relevant to this particular hill I will die on. I think in order to, give DPCA better rep with fellow physicians, which will then trickle down to patients as well. We need to show that this is not some crazy alternative medicine. This is good evidence-based quality care that is provided to you in a personal, transparent way, and it's, eliminating a lot of middlemen to put you and the doctor back at the center of primary care. And I understand the allure of doing some of these other cash based services, like for instance, aesthetics or, aesthetics, not, there's nothing wrong with aesthetics. I'm not saying these things are morally wrong. I. All I'm saying is when we add all of those bells and whistles, yes. It's other revenue streams. And I know people have to support their families and have to keep the lights on and have to pay their staff. And there's so many reasons that doctors end up doing these things. So again, I don't wanna pass judgment and say these are just all wrong and bad, but. I think when we do that, we dilute the mission and people start to forget, and again, they just lump you in with these med spas and wellness places and don't think of it as real medicine. And we are doing real medicine. We're doing real medicine the way that it's meant to be done, the way that I think so many of us have wanted to do it, but couldn't because of the confines of, the insurance based healthcare system. I encourage everyone who's in my course to stick to evidence-based medicine. I actually, I, so far, I don't think I've had anyone do my course that is, not doing evidence-based medicine. I, that's gonna be a uncomfortable day for me. But those are the people that I really wanna support. And it's just something that I personally feel passionate about. Again, not wrong. If you are doing other things that I think everybody who does. Things that I don't consider EBM believes there's evidence for them. Anyway, it's debatable where you even draw the line, but I just think as much as we can continue to position DPC as a, just a high quality medical care option, not some alternative or compli complimentary medicine, but high quality primary care. With transparency and time and that personal relationship component I think the better we will all fare in the long run. All right, that's number four, EV, m or bust Number five is. Be yourself. I don't think anybody would disagree with this. I think probably anyone in the DPC world who's, mentoring a physician would encourage them to not try to fit into some other mold. And they would remind you that, if you've seen 1D PC, you've seen 1D PC. So there's so many ways to do this. But a mistake that I see a lot of. Newbies and people who are trying to start practices make is that they'll look at somebody else who's already successful and then they'll just be like, okay, I'm just gonna do that. I'm gonna do exactly that. And this happens to me all the time where people come to me and they're like, I just wanna do exactly what you do. I just wanna have a website just like yours. I wanna have a patient population just like yours. I'm just gonna do exactly what you do. That could work. That could work. And actually I've had a few people in my course and otherwise that. I meet them, I know them. We're we're millennials. We have children the same age. We like the same stuff. Like I we, we dress in the same, they'll all be like, oh, I have that top, so there's times when I think, okay, yes, this person is just, we're in that same exact demographic and they like the same things and are drawn to the same things and have a lot of the same shared values and, whatever. It's not surprising that person's practice is gonna look a lot like my practice, but I think there's other times when actually. That person has a totally different vibe and has a very different approach, and it's a mistake for them to just be like, oh, let me just, lemme just do exactly what you're doing. Or maybe they have no interest, for instance, in women's health and they have never had any interest in women's health and suddenly they're like, I'm gonna deserve a for women. It's you can, you definitely can. We're all allowed to pivot. We're all allowed to change our mind. We're all allowed to learn new things. But I think there's a certain magic that happens when you create something that is authentically you and that is informed by your experiences and that feels like you. That magic thing is not gonna happen if you've just copied and pasted or, tried to duplicate what somebody else has done. I also think, again, that duplicating the practice model of somebody who is not like you can lead you down a very bad path of burnout and inappropriate pricing and wrong patient population being attracted to you. So many. Things can go wrong when model your practice. For instance, it, it would be wrong for me as a female physician who attracts a lot of health, anxiety and chronic pain and has a practice focused on women. And is in a big city with a ton of other primary care options to model my practice after a doctor who is in a small or mid-sized town who is male, who maybe does not attract a lot of those patients, whose patients are generally elderly or, yeah, I mean it, when you think about two different doctors in two different places like that with different experiences and clinical interests and. You're going to get a totally different patient mix, and I just think that you have to take all of that into account when you're deciding how you're gonna design your practice and how you're gonna present, who you are and what you do. I think again, we are too trained to kind of stuff down all of the personal things about ourselves. Usually there's this whole paragraph about who you are professionally, and then there's one line that's and she enjoys gardening and cooking and traveling and spending time with her two children and dog like that. That's who that, that's all usually we give out of ourselves as human beings in medicine, but. I think the more you can infuse your practice with who you are. I'm working with somebody right now who loves diving and we've decided that she's gonna do a ocean type vibe for some of her branding, which I thought was beautiful.'cause that's her, the physician who I mentioned in the last episode who sent me her website her. Practice is focused on taking care of multiple generations of a family. Like she really loves that, taking care of people. As well as their parents and their children because supporting all of those parts of the family supports that person in the middle better. And she had a really beautiful tribute to all the generations of her family that led to her career in medicine. And I thought that was the part that made me cry. It was just'cause it was just. Not only did it speak to the mission of her practice, but it spoke to her core and her essence and who she is. And all of that stuff was aligned. Her branding, her, the voice, the every, all the words she put, all the pictures she used on the website, all of that was speaking to her core and that, that's why it made me teary.'cause that magic thing happened. And so the more you can infuse your practice with elements of you. The better. And I think the more you can do that, the more you distinguish yourself from everybody else. And when it's real, people can sense that as opposed to when you're just trying to play to the audience. Say stuff and do stuff and put stuff on your site that you think they'll like. Okay, so that is the last one, so all five of them. To summarize, get a lawyer. Branding matters, price appropriately, evidence-based medicine or bust. Be yourself. So those are my five hills that I will die on. I'm sure I'll come up with others over time. But those are the five. Like I said, if you've been following my stuff for a while, you've heard me say all of these things. I think, I. Everyone in the DPC world, especially, like the big voices, we all have our own sort of flavor and brand of DPC that we promote or try to encourage people to do. And I just think these are the features of what I talk about a lot and what I want to help other physicians create. And some of these trying to remember, actually not all of them, but most of them. Are part of what I call the micropractice mama special sauce. I'll talk about this a lot more in the webinar, but basically, the Micropractice mama model is direct care. It's micropractice. And it's something called the special sauce. And the special sauce has, I think, I don't know, seven or eight ingredients. And some of these are in there, but those are what I think define my particular flavor of DPC. So if you wanna know more about what's in the special sauce, I share all the ingredients of the special sauce in that webinar that's coming up September 10th. At 8:00 PM Central Time on Zoom, the registration link will be in the show notes. That brings us to the end of the episode. Reminder that I am doing a q and a episode this season. So if you have questions that you want me to answer please feel free to send them to me. Sonia@micropracticemama.com. I don't think I'm going to say anyone's name who sent me the questions, so they will all be anonymous, so don't worry about revealing yourself. I hope to hear from you soon. Love getting your feedback. So any other feedback is welcome at that same email and hope to see you guys next week. Bye.