Q&A Episode: Handling Admin Tasks, Saying "No" & My Hot Take on Executive Physicals

In this episode I answer listener questions including,

• how do handle administrative tasks that are normally done by an MA, referral coordinator, etc.?
• what are my tips for doctors who are direct care specialists or don't plan to do primary care?
• who are the hardest patients to turn away?
• plus my hot takes on non-physician run DPCs and executive physicals

If you're enjoying this pod, I would love to connect! Real human feedback is so deeply appreciated. Here are a few ways to reach me:

Connect with me on IG @soniasinghMD
Email me at sonia@micropracticemama.com
Learn more at www.micropracticemama.com

The Micropractice 101 E-Course is available NOW. Learn more or enroll here: https://micropracticemama.thinkific.com/courses/micropracticemama

And if you're not sick of my voice yet, check out my other podcast with Dr. Rebecca Berens: The Antisocial Doctors on Apple Podcasts or Spotify!

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Transcript

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. Hey doctors. So this week's episode is the q and a episode that I have been talking about for a few weeks now. I have seven listener questions that were sent in and I'm gonna go over the answers to, but I wanted to start the podcast today with a little shout out. So first a confession and then a shout out. The confession is when I started this podcast a little over a year ago, I don't think I looked at the reviews for it on any of the platforms for maybe at least six months because I was terrified of seeing a bad one. And as some of you may know,'cause I've mentioned it before, I had abandoned A podcast in the past where I had started it and never finished. And I had a lot of shame about that. And I, had this little voice in my head. Thing that might happen again, you might just give up on this. I might get taken over by imposter syndrome and decide I'm crazy for even trying. And so I was afraid that if I, looked at the podcast description and I saw a. Terrible review of someone saying who does this lady think she is? Her voice is so annoying, blah, blah, blah, that I would just crumple into a ball and die and I might never finish it. So I avoided looking at the reviews and then at some point I was like, you know what? I should just rip the band. I should just look. And I was pleasantly surprised that they were all very nice and I'm so grateful for everyone who took the time to write a review. I know you don't have to do it, obviously. And so I think you know, the people who. Actually take the time to write something thoughtful. That's so hugely appreciated. I do read all of them now. And it helps other people find the podcast and more doctors to find this information, which is the most important thing to me. So I wanted to start by giving a little shout out to somebody who recently left review. So the review is titled Micropractice Grandpa. And he says, I'm a 63-year-old, father of four, grandpa of 10, and I'm launching my own DPC practice on August 14th, 2025. Dr. Singh's podcasts have been very helpful and inspiring. I appreciate her willingness to be vulnerable. She even responded to an email concern I sent her, keep it up, Dr. Singh. Oh, a micro practice grandpa. This just goes to show I, I'm always keeping. A certain type of doctor in my mind when I'm making these episodes, but I never know who's listening. And Dr. Mayberry did reach out to me with some constructive feedback and I deeply appreciated that. I just so love that he's listening and that he is starting his DPC and that just tells you it's never too late. So I just wanted to say thank you to Dr. Mayberry for that very kind review and for engaging and for sending me feedback. And I hope you had a great first week with your DPC. I think I'm gonna do that more often now. So if you leave me an interesting review I'm gonna give you a shout out because it's fun and it's a way for me to thank you and, engage back. Anyway moving on. So let's talk through the questions that we have. Let's just get straight into it. I was feeling a little. I worried that I had done too many motivational woo type episodes lately. So hopefully this episode gives you a little bit more concrete meaty stuff. There's more protein in this one, so if you're just here for logistical tips you should like this episode and then next week we'll go back to some more woo stuff maybe. Anyway, so the first question I got. Was, how do you learn all the clinical and administrative activities like how to send referrals, receive referrals, get records, do PAs, other things that in corporate fee for service, jobs are handled by referral coordinators, MAs other staff members, et cetera. Okay, so I, for this question, I would point you back to an episode called How Do I Dot, dot. Do. In that I do go through like a lot of the, like a broad overview of some of the logistical tasks in Micropractice that people often ask and wonder about. Just to give you a brief framework for how I do most things is. First of all, I will say all of those things that were mentioned in that question are probably way easier than you perceive them to be when you're an corporate healthcare environment and someone else is doing it for you. I think there's this learned help helplessness that we all have when we work in those environments.'cause we just have this idea that all those processes are so complicated, they need to be handled by a whole different person. But you're usually smarter than most of those people who are doing those processes. You are definitely capable of doing them and in a lot of ways you can do them better'cause you know the patient and you know the clinical scenarios and you know all the information that is actually needed to do those things. But anyway it's a lot easier than you think. So for any of these processes, I would just think about, okay, what is actually required for that test? For instance, doing a referral, let's say I wanna refer somebody to cardiology. What is really actually required? What is required is typically some sort of records or reason for why I am sending the patient the background of them, and a fax number. And so if you're not working with a restrictive A-C-O-H-M-O type. Insurance plan, like if the patient just has a PPO, you really don't need a whole lot. Sometimes part of the specialist's office protocol is that they need some diagnosis code to just have on file as the reason for the referral. But if the person has a PPO, sometimes you don't even need to have a technically a diagnosis code. Like they can just call up the office themselves and schedule the appointment if they wanted to. So you're doing them an extra favor by sending the records and your thoughts and the reason for the consult, right? All you need is that doctor's fax number and you need to fax your records with a diagnosis and an order. And the order just will say. Referral to cardiology, and usually I put the doctor that I wanna refer to in parentheses and I attach the records, any relevant labs, and I fax it. And a lot of times if I know the doctor personally, if I have their cell phone number or if it's a complex patient, usually it's just I try not to ping them for every single person I send. But if it's urgent or complex or I think there's a heads up they need, I will also shoot them a text and just be like, Hey, FYI referred this patient. Please let me know if you have any questions. I will tell you the hardest part of that whole process is just finding the fax number. Only when I started my own practice did I realize how annoying it is when you do not put your fax number on your office or practice website. So many places, especially these big corporate. Health systems, they just, they will have a beautiful profile of the doctor, but there just won't be a fax number. And then, sometimes you're unsure if there's a different fax number for records or a different fax number for referrals or a different fax number for clinical informa it's it gets very confusing. So honestly, the worst part of the task is acquiring the right fax number. So you know, once you think about, okay, what is needed for this task? Map it out, these are the steps to do this thing. Then I would say, do it. Notice where there's friction. So this kind of brings me back to my, like I, I did some sort of certificate through some organization at some point, which I cannot remember the name of on Lean Methodologies and five s and all that. All the good quality improvement stuff that the Japanese have taught us. So anyway, I. This is where that thinking comes into play, where you look at the process and you think, okay, where is there friction? Where am I running into a roadblock where I get annoyed with something. So in the case of referrals with finding the fax number, I think a way to reduce that friction is just every time I do a fax to somebody, I save it as a contact so that hopefully the next time I do it, I don't have to type it in again or find the fax number. And so that has become much, much easier as I've been in practice more years, because the first time I do it, I just save everybody as a contact. And then it's an. There for the next time. And I can go in and correct it if I find out later that it's the wrong number. Another place, like for instance with getting medical records for somebody. So the way I had it before is like I had this form that people would sign and then I was using they would e-sign it through intake queue, and then I was using Doximity as my free fax. And so they would sign this form, then I would download it, then I would upload it to Doximity. Then I would, find the old PCPs fax number and I would fax it to them. I was feeling a lot of friction in the whole downloading and uploading part of that, like that felt really annoying. And there's certain tasks you do where you're like, I just feel like a monkey. This does not require an md. This feels like I should not be doing this task. So I was annoyed by that task, so I realized that. Intake queue allows you to buy fax credits, and that means that you can actually fax directly from IntakeQ and you don't have to download anything. So it's they sign the form, it comes back to intake queue, and then there's a little button next to it where you can just say fax and you can type in the number and you can buy certain number of credits and then you can just hit fax. So that allowed me to skip the whole step of downloading and uploading, which, for me made it. A lot like I, when there's friction in a task like that, I tend to procrastinate it. When I, when it's unpleasant in some way like that, I'll just be like, oh, I'll do that tomorrow. I'll do it later. So I felt myself doing that and once I made that change, I was generally much quicker to be, like, as soon as I got that records release signed, I would just immediately go in and fax it off and wait for the records. Yeah, I would say generally what I would do is think about what is actually required for that task. It's usually gonna be way easier than you think. Map it out, try it, see where there's friction. Make changes to reduce the friction. And if there's any way to automate that process, automate it. And then if you want more granular detail on, different tasks like ordering labs and stuff like that, go to that, how do I episode and listen to that?'cause I went through all of those in detail. Okay. Next, what processes have you streamlined? I'm thinking of things that office staff and private practice do that you are now doing more efficiently in Micropractice. So this is a similar question but I guess it's more specifically asking what things have I. Found a way to streamline or reduce friction. And the biggest thing I would say is just making sure that a patient who is interested in joining your practice has the ability to enroll, schedule, and do all their paperwork without you lifting a finger. That just makes it so that their experience is really smooth and efficient and fast. And then you yourself don't have to do anything when somebody is trying to join the practice. Except celebrate. The way I do that is basically with Hint, hint is my. A membership management platform. And Hint allows you to set all these different notifications when certain things happen. And so right now I have it set such that when a membership is confirmed, it immediately sends an email to the patient with the new patient forms, the medical records release. And my scheduling link and used to also send the spruce link, but I ended up taking that off and now I give people the spruce link during the first visit. But basically, that whole process is on autopilot and don't have to do much at this point for it. My, my process with getting records is as I mentioned, I, have the form come back in intake queue. As soon as I see it pop in, I just go and fax it to the place. And then typically, two days before their visit, I, I'll always be looking at my schedule a couple days ahead and if I haven't gotten the records two days before, I usually call the office. And honestly. Getting records back from places, I would say I have a 60, 70% rate of them actually just sending them without me bothering them. But a lot of times you have to call and say, Hey, I sent this records request. I find it much more effective to send the request and wait a few days because. When I call and I can say, Hey, I sent you this request one week ago and I have not got anything. And you're the doctor calling, so usually they're like, oh no, we'll send it right away and they'll send it to you. Whereas if you call the day you fax it, they'll be like, oh, I know we didn't get it yet. We'll check our fax later. And then there's no urgency to it and, it can take them two weeks to, to actually send the record. I usually two days before we'll start. I'm trying to follow up on the records, and then typically just the day before I will go through their new patient forms and populate their chart. The chart is automatically created in my e emr, acute, but then right now it doesn't have an easy way where all the information they put in the form flows into there. Go in and put that in. It does take time, but honestly for me it's this is like the way I used to study when I was in college in high school is writing stuff down or transferring information or taking notes like that is the way I absorb and process information. So I think other people might find that really annoying. But for me it's like when I sit down and flesh out the chart, that's when I'm pre-thinking about the patient and preparing for that visit. And I find that I go into the visit. A lot more prepared. And I, the time is used more efficiently when I've had the chance to do that at my own pace, as opposed to, I've had one or two patients show up without doing the forms where I've reminded them multiple times and then I think they think it's an old school office where they're gonna sit in the chair and I'm gonna hand them a clipboard. But. That's not how it is. And so we have to start from scratch. And I go through the questions that those visits are never as efficient and I feel like I'm mentally trying to catch up as they're telling me information. So it's a very different experience when I get to do that kind of pre-visit stuff myself. Other things that, I've streamlined I now use an AI note writer for basically every visit except for the first visit. I could use it for the first visit, but I like to write out the assessment and plan for that visit. And I like it to be in my own voice. I like it to be after I've taken a lot of time to digest all the information and think about it. And for subsequent visits, UR eyes, blood pressure, follow ups, med follow ups, those are so easy to do with ai. And I find that AI generates great patient instructions and it works perfectly for that. But I don't know, again, for me the process of writing that first assessment and plan and coming up with a goals and, a game plan for them is, a lot of what they're paying for. That's me filtering and processing the information through my own brain and my own clinical experience and my perspective. And so that part I still do. But everything else I use AI for. Now I have integrated lab and imaging ordering through my EMR. The lab ordering is pretty good in that, I can order it to Quest LabCorp directly from the EMR, and it comes back directly to the patient's chart. It's not quite as pretty as the results review you would see in Epic, but it does go in there and you can, see the values without opening the document. The imaging is not quite bidirectional. Like I can order imaging things. To a lot of the common big imaging places in my area through my EMR. But when it comes back, it does not right now it does not go directly into the patient's chart. It, it comes in as a. Generic fax and then I have to assign it to the patient's chart. But still the fact that I do not have to go in and find every fax number for every imaging place. Like all of that is now in the EMR for me before I had integrated ordering, one thing I did to streamline was I pre-filled out the common imaging places that I was using. Like for instance, solace mammography or there's a place here that does memorandums called the Rose. There are a few that have a standard ordering form that can be used that you can fax to them. And so for the ones that I used really commonly, I. Would just pre-fill the parts that were always gonna be the same. So the information about my practice, the address, contact information, my NPI sometimes I would even, like for Solis, I would just pre-fill the standard screening mammogram diagnosis code and check off that box. And then if I needed to adjust it, I would, but that saves you a lot of time'cause you don't have to keep filling the same thing out over and over. And I fill all of my forms on, what do I fill it on? Preview, I don't know. I have a MacBook, so I guess it would be like maybe Acrobat if you don't have a MacBook. I, whatever program it is that you look at, PDFs in often has an editing function. And with what I use in preview, like you can you can save your own signature. So like my signature's on there, it has a place where you can just like, stamp the date. So a lot of the, forms and stuff that you get that I was previously signing on paper and then an ma was scanning and faxing and uploading to the chart and all that. I just don't do any of that anymore. I just do it all, on the computer. And and basically paperless. I also have a ton of auto phrases and. Smart phrases. If you use Epic, you'd call'em smart phrases, but auto texts basically for things that I say a lot or send people a lot. Just, explaining mild vitamin D deficiency, severe vitamin D, explaining what to do about a high LDL, explaining what a slightly high bilirubin means, explaining what you know all talking about pre-diabetes, like explaining all of the things that. I typically respond to lab results with my recommendations for UR MRIs. Just every FAQ and thing that you find yourself typing often save it as a smart phrase or an auto phrase. It will save you so much time. And then lastly PAs came up a couple of times in these questions, I use now CoverMyMeds almost exclusively for all of my prior authorizations. If you're not familiar with CoverMyMeds, it's a PA platform. It's totally free. You don't have to pay anything for it. You can go in there and fill out a profile and there's one or two steps. I can't remember. I think it's like they send you a fax and you have to verify it or something, but there's a couple of steps to make like a full account. And once you've done those couple of steps to verify your information, the PAs will automatically get sent. To your cover My Meds account. So the way I used to do it before like even in standard practice, was sometimes they would send me a little key and it would say, go to cover my meds.com and use this access key to access the pa. And so I would go and type in the key. So now that, I verified my account it sends everything directly so I don't have to type in the key, it just comes directly to my inbox There. And so once you've filled out the, your profile and everything, it's really nice.'cause a lot of this stuff gets auto-filled. Typically the first section of the PA is the patient's information. And if you have a decent pharmacy, they usually have filled that out correctly. Sometimes they just leave everything blank, which is very annoying. The. Contact information address, and everything should already be there. And then the second section is usually prescriber information. And if you filled out your profile and cover my meds, that's all completed. Your NPI and your address and your fax and all that stuff is completed. And then you just have to go and answer the clinical questions. And a lot of times you get an instantaneous approval or denial. No, usually it's an instantaneous approval or it'll say, give us 24 hours, or we need more information, or whatever. But it's such an easy way to just be able to keep track and you can go back and check the status, so it'll tell you if it's still pending, if it's been approved, denied, it'll have a copy of the denial letter. Before I was using this, there were so many times when, I would be like, can you ask the pharmacist if it's been approved? Or, can you ask them to explain what are the covered alternatives or why it was denied? And now I don't have to do any of that because it usually is all. In CoverMyMeds when I very occasionally have an insurance that will not work with CoverMyMeds, it like really sucks my soul to have to call those terrible numbers and the do the PA via the phone and sometimes you have to do peer to peer and all of that is terrible. So anyway, cover my meds, I would say is the least painful way to do. PAs and I have no affiliation with that company. So no kickback. I'm just telling you what I use. Okay. Next how are your recommendations different for marketing slash packaging slash pricing for specialty practices as compared to primary care? I try to speak to what I know, which is primary care and. I've designed my course around that. And what I tell people who are interested in the course or enrolled in the course who are not in primary care to do, is to, I let them know this information will all be helpful for you, but you are probably going to have to seek additional information from people in specialty practices or specialty DPC practices specifically in your field. To have really all the information you need to start your practice. My first piece of advice would be look at what other people in your space, in your field are doing and learn from them. And, find a mentor in that space that can teach you what they've learned. Because I do think it's a different beast, although, some of the basic stuff is gonna be the same. I don't think there's honestly that much difference in marketing. Maybe in just the way you position yourself and talk about the practice, but the biggest difference is I think you probably will have to structure your payment model a little bit differently than a traditional DPC in general. For a regular direct primary care practice. I'm very antia la carte services. I shouldn't say very. I'm generally antia la carte services. Like to me, when you switch over to a la carte, you're going back to a volume-based model, and that's what we wanna get away from. And I think a lot of people will do that and say, oh, but I, it gets people in the door. I, just, I just need some traffic or a lot of people are just too afraid to commit. And the thing is, I think you just when you have that as an option, it's gonna be very attractive to a lot of people and you're going to filter out some people that probably would've sprung for the membership if there was no a la carte option. And you're disproportionately gonna get a bunch of people who are just. Non-committal and don't really want to have a long-term relationship, and they're just gonna use you for a la carte service, and they're going to squeeze every bit of use and value out of that as possible. And to me one of the big beauties of DPC. Is that it's not a volume game. It's a relationship based model, and there's this free open communication between you and the patient, and nobody is counting the minutes. And if they're reaching out to you, you don't immediately feel this resentment of oh why is this person now, like I just spent an hour with them. Like, why are they trying to ask me a question? Because your time has already been paid for in the membership based model. So what I would say for. Specialty practices is that you have to think about what do people need from you? What do they want from you, and how do you anticipate them using your services? And I think it really is gonna vary depending on what your specialty is or what kind of services you're providing. For example, I think if you're doing weight loss medicine or obesity medicine, I feel like there's a ton of models out there that you can. Try to replicate or, use to, to build off of. And I do think weight loss can be very structured. You can have monthly check-ins, you can be very clear about what the goals are, what the deliverables are, like, what you're providing, which medications that you, prescribe and blah, blah blah. I think all of that actually you can provide in a pretty structured way. Something like menopause management, I honestly think is a lot more messy. And I just say that based on. My own experience of treating menopause and perimenopause in my practice. Like I find that those patients tend to check in with me a lot more. And maybe that's because I have a membership based model and they know that they can, but they tend to have a lot of questions. A few weeks in it's how exactly do I use this? And what if it fell off? And what do I, is this. Possibly a side effect. Is this not a side effect? What do you think about incr? Like there, it just feels like with those patients we do a lot of asynchronous non-face-to-face follow-up messaging. And I don't know if you can have quite the same discrete type of package for that. But basically I would steer people who are doing specialties to. Structure as much of their services as possible in the form of some type of package or some type of three months, six month, one year. Like I can see a great option for menopause care being like one year navigating the menopause transition. So it gives you wiggle room that, if you say three months, three months. To me is not enough to even know if something is like totally working, so I just I think you really have to delve into what do these patients need from a medical perspective? How long is that likely to take? How many touchpoint are needed for that? What kind of follow-up care is needed for that? What kind of labs, what kind of in-person visits, what data? And also. Concurrently, because it's often very different. Think about what does the patient want and what are they expecting and what, what are they gonna be, wanting to get out of this? Because sometimes those are not the same, and think also about, maybe the patient population that's likely to use that service and how they might like to communicate. That might be very different for a geriatric population versus a young, healthy population. So I think you have to really think about your patient population, what service you're offering, how that's going to look and design your services accordingly. And I think you just have to also remember that you can change things. So whatever you start with you don't have to do that forever. And you can always change things around if you find that, you're having a certain experience that's not working so. My experience, I've mentioned this before, was that when I was pregnant with my second baby, I decided to start offering an a la carte physical. I called it just a physical. It was like a wellness consultation slash physical. I would do the things I would do in a typical insurance based physical, but then I also spent a lot of time going through diet exercise hydration, stress management, sleep, social connection, purpose, like all the lifestyle pillars of health. And giving concrete advice on how to optimize those things. So it was a long visit and then it included labs and I would do a follow up for 30 minutes phone or virtual to go over the results of the labs. And that was like one little package that was meant to be completed over 30 days. My experience with that was that a lot of the people who. Sprung at that opportunity were, and I only offered it by word of mouth and I shared it on Instagram and in a physician group, so I didn't even put it on my website for the general public. I think if I had done that, it would've been even worse, but in general, a lot of the people that signed up for that, a la carte service. Were inappropriate for an Oli art service. I tried to emphasize in the brochure about it that you know, if you have multiple chronic conditions that you're dealing with or you're a complex patient, this is not a second opinion service. If that's the case, you should consider just joining the membership. You can always cancel the membership. In my structure, there's no long-term commitment so they can cancel with 30 days notice. I would always say to those people, you just don't know. How long it's gonna take to go through whatever your issues are. And I would like to just have this open line of communication if, you know you have a lot of issues or you have a complex case, or you need a lot of care coordination or whatever it is. Join and even if you're not sure, you can commit to a long-term thing, you can cancel after a few months if we sort your things out, but people don't listen to that so I had a lot of people who signed up for that one time wellness visit that came with a long list of problems. Things that it, I was definitely not gonna be able to solve in one visit and one follow up like impossible. And several of the people who did that service were just pinging me three months later. Six months later. Oh, but can you please just, can you just fill my singular, can you just fill my, and then I felt the resentment. I was like, this is not what you signed up for. There isn't clearly an option for you to do something that would allow me to, have ongoing care with you and answer your questions and all these things, but you did not choose that. And so it was very, that's that feeling. I don't like that, I don't like having that feeling towards patients. And so I wanna avoid putting myself in situations where I have that feeling towards patients. After my pregnancy, I basically nixed it. I still do it occasionally for fellow physicians who are just like, oh, I just I haven't had time to go in for my physical. I really need to do my physical. So most of those patients they understand and they're not abusing me in any way. But and then sometimes I do offer it for like adult children of current members or spouses of current members. Again, because I think when one of their family is a member. There's a certain amount of loyalty there and they understand also what the services and membership is and what it entails and they can make that decision about whether it makes sense for their spouse or not.'cause I do have a lot of people who will just sign up their spouse even if they don't see me very often. So anyway, that was my experience doing an a la carte service. That's just me. That doesn't mean no one can do an a la carte service. I think there are definitely a ton of DPC doctors out there who do a la carte services and do them and, have a good experience with them. And with a certain patient population, that might be fine, and I think the main question to ask yourself is does this person have access to me between visits? Is that easy access? Am I gonna be responding to that? Because that is where when you do the a la carte thing, you run into trouble is when there's follow up questions or they start asking for requests outside of the visits because you are not being paid for those in any way. You can start asking for money for those, like you can charge something per message. But then again, that is exactly the system that I was trying to leave where. The patient feels nickel and dimed for everything that they do, and you also feel like you need to keep track of every message and every minute that you spend and bill for that, which is just not a fun way to do our job. Okay. That was long-winded. Okay, so next question is when is it hard to tell a patient? No. To be honest with you, I wasn't sure exactly what this question meant. I don't know if she means what makes it hard to tell a patient no. Or what scenarios have I been in where it's been hard to tell a patient? No. I will say that the times I have had the hardest time saying no to someone is when I already know that. I'm probably the best option that they have or the only option that they have and I can't point them towards someone better. There's a lot of situations in which I tell patients no, in terms of being in my practice or staying in my practice or whatever, that I do not feel bad about at all because I just know that they're not gonna get what they want from me. And those are often situations where somebody. Is, what they're really looking for is probably a functional doctor or a naturopath or something. And that's not what I am, and I just know that they're gonna get it and they're gonna get disappointed because we will not see eye to eye. So those people, I don't feel bad at all saying no to. And it's best for both of us that I say no to them. There are some people just from the way that they interact with me in the meet and greet, or they leave the way they, honestly, the way they talk on the phone sometimes when they don't realize that the doctor has answered that rubs me the wrong way and makes me feel like they just they're just not a very nice person. And so those people, sometimes I, I. I, I don't feel bad saying no to them, but sometimes I have a hard time finding a way to do that. In a way that they understand can, I can't just be like, I get this, say you're not very nice, I can't do that. In those situations, in the meet and greet, I'm trying to scan for other places where there may be a disconnect and I try to focus on that. But sometimes they don't reveal any. And so then you're like, okay, I guess we'll see how it goes. But I think a lot of times those people. We will show their true colors very quickly, and then there will be like a little bit more of a substantial reason to say you disrespected my boundaries, or I don't think we're on the same page. Or I I don't think this is a good fit and whatever. But, i've had two cases where I actually had to dismiss somebody from the practice. One was somebody who lied to me about their controlled substance use. And that was a very clear, like I just, I ran the controlled substance report, it's called PDMP report here. And saw that they had gotten a duplicate prescription and that. Clearly is against the rules. That is against my controlled substance agreement. And I was very clear about that when I signed this person on. And so I had to have a very uncomfortable, I was very uncomfortable. I was nervous and couldn't eat like that day that I was like supposed to have this virtual visit and lay it out for this patient. But, I knew that was the right thing to do and I felt very justified in doing it. But, part of me did feel. Bad about it because I, I think this patient was just really struggling with addiction and mental illness, and his family was doing the best they could to help him. And, it I just knew he was gonna keep running into this problem over and over, and it was sad. The other patient that I had to dismiss was a unique situation in which, this patient had like a devastating, intracranial hemorrhage, but basically he was now bedbound and required 24 hour care and the family was essentially trying to provide like hospital level care to this patient in their home. And, they were like, we really want a doctor that's willing to come see him at our home, but if you can't do home visits, we would understand that. And I didn't. Really commit to the home visit. But I was like if you're okay with mostly doing this virtual and remote, we can try it and see how it goes. I did not understand his level of medical need at the time that I did the meet and greet. And within a week I was treating hypernatremia and like just all these things that I really did not feel comfortable with having not been in a hospital. Setting for so many years. And also just, handling it all remotely it just it felt outside of my scope. And I. I told them I, this feels outside of my scope. I don't feel comfortable with this. I don't think I'm the right person for this. I, these are issues that I have not treated for years and I just dunno if I'm really the best person to do this. And the patient's wife was like, then who is the best person? She was like, name your price. You just tell us what you think this level of care should cost and like we'll pay you that. But ultimately it wasn't about the really, it wasn't even about the time or the money for me. It was just like, I did not feel qualified to take care of that patient. But she then was like could you point me to somebody who could do this? And I thought maybe a hospitalist who's willing to take on a private patient, or I'm sure there's some concierge doctors out there that have done more inpatient work and feel more comfortable with this, and I looked around for her'cause I really felt for this family, I could understand why they were trying to keep this guy outta the hospital. It was just like, every time he went he would get some hospital Corona infection, a cycle would continue. And I looked so hard for them and I know they contacted several people, but they really couldn't find anybody. And in the brief time that I took care of this patient, she was like, oh, this has been such a relief. There's so many times when. We just want labs to be drawn and we go through this whole complicated thing and we reach out to the ID doctor and then they fax something to home health and it always takes four days. And and it was so much faster when, I was able to put in lab orders immediately and they had a mobile phlebotomist and I knew that I was probably the best option that they had and that was the best experience that they had with A PCP. And I could not point to anybody else who I felt like could do a similar thing or would be willing to do a similar thing. So I felt sad about that. And I still keep in touch with the family because I still I wish the best for that patient and I hope they're able to find, the right kind of care for him and the right doctor. But it wasn't me. So anyway, those were a few situations where I had to say no and it was hard. Oh, I had another patient who, oh gosh. It was very complicated and very sick. And she had this complicated relationship with her mother, and then her mother started calling me, and I of course, could not reveal any information to the mother about her, but the mother would be saying like, I'm concerned for her safety. I think you need to go to her apartment and take her to the er. And then I would be talking to the patient. I would be like, I just don't think she's unsafe. So that was a very, that was very uncomfortable. Situation. But fortunately that patient ended up moving out of state and leaving the practice and moving in with mom, I believe actually. Anyway there were, I've been in a few strange situations in which I had to say no to somebody and it was a little unpleasant. But general, I think, you just have to ask yourself like, why do I want to say no to this person? And is that justified or is there some other reason? I've had a few patients that I really wanted to say no to because they had. Previous diagnoses that I did not agree with. Chronic Lyme, like certain types of mold toxicity or mold toxicity is real. But, they were attributing symptoms to it that I did not feel were likely to be attributable to that. And I explained to them in the meet and greet I probably have a different view than this previous doctor that you had. And I was worried that, they were gonna join the practice and then again be immediately. On a totally different page as me and find my perspective and views to be upsetting or offensive or, crazy or whatever. And I've taken, a few, a handful of those people because they really seem to express no, I've been there, I've done that. I want a more conventional medical perspective. I want somebody whose evidence. Based, a lot of them are not totally willing to let go of some of those previous ideas, but they're open-minded enough to talk about them in a respectful way. And I have taken some of those patients and for me it becomes very emotionally and intellectually draining because I'm like, I'm trying to understand things from their perspective. So sometimes I have to delve deeply into this underbelly of alternative medicine. In that I don't particularly enjoy learning more about at this point in my career. And then I have to delicately handle. Sharing my perspective without making them feel invalidated or, gaslit in some way. And that's hard. It's really hard to do. But all of those people are still with me, the ones I'm thinking of. And, honestly, they're good patients. They don't abuse my boundaries. They listen to what I have to say. The worst that happens is sometimes they still seek out some of those alternative perspectives. And, I. I would say the biggest red flag to me would be if they were doing that and not telling me and doing it on the side. But most of the time they're open with me about, oh, I'm gonna go see so and and I'm just gonna get their thoughts on this. Okay. All right. That's fine. As long as you are open to what I have to say and, we are interacting in a respectful, professional way, then it's fine. Okay. Next question is what do you think about DPCs run by non-physicians? I'm honestly, I'm just not even gonna touch this. This is one of those, like the whole NPPA versus MDDO thing. To me, the whole thing is just not even. Worth an argument. But I, what I will say is that I don't think credentials or pedigree or any of that stuff is like a make or break. Like you can come from a fantastic background and institution and have all these fancy names on your resume and you can be a terrible doctor. Like you absolutely can. And you can be an NP or a PA without an MD or a do, and you can be really engaged and empathetic and you can be listening and you can be doing appropriate medical management and doing appropriate workup. I think what a lot of people say is oh yeah, I see the np, but I had such a better experience with her than I had with the doctor. And I think that's, honestly, I think that a lot of patients have that have had that experience and I can't deny that. But I would say, if all other things are equal and I was choosing between an excellent PA and an excellent MD or a do like I would probably choose the MD or a do, in many states, those people are, supposed to be supervised by an MD or a do. So it's would you go to the person who's being supervised or would you go to the person who's. Supervising them. So I don't know. I don't, honestly, this whole thing, I'm sure there's some nps or PAs that have listened to this podcast or listened to this podcast. I'm not here to try to belittle you or offend anybody. But I just find the whole debate to be unproductive. But one thing I will say is what I've noticed is when people are not. Just good doctors or good clinicians, I should say. When people are not good clinicians, as in they don't have a good fund of knowledge they don't have good bedside manner. They do not, know how to do the intellectual work of developing a differential diagnosis and working through it. They're not empathetic and validating and they don't care. So when you are not a good clinician, you. Will very quickly jump to bells and whistles and nonsense. So to me, whenever I see a practice that has a bunch of bells and whistles and nonsense, and by that you know everybody, we all, we do and we do aesthetics and we do compounded meds and we do pallets and we do B12 injections on people and we do iiv vitamins and we do, just just everything we do everything, oh and we order genetic testing on everybody and we do a full body MRI and everything. Whenever I see that's. Stuff. I just think what are you hiding? Like what are you trying to compensate for? Basically what I think when I see a truck here in Texas with really gigantic wheels, I'm just like, what? What are you feeling insecure about? That you feel the need to do all of these other things because the reality is. The bar set by traditional healthcare is so low that if you just go out there and spend more time with people and listen to them and think about their problems and just do a decent job, working them up and explaining what workup you're doing and what the results mean, you are already giving a better patient experience than 99% of doctors. Anyway, that's my 2 cents on that. Alright, last rant here. Last question slash thing that I'm gonna rant about. The question is, what do you think about executive physicals. As I mentioned, I have done a standalone physical slash wellness visit. All that was special about it was just that it was longer. And I went through all those lifestyle things in a lot of detail. There was no other. Enhanced services. It was just a normal physical, basically what I think of as a normal physical. So executive physicals, first of all, what are executive physicals? I feel like historically they were physicals for a. Middle aged or older male executives. And when I think of executive physical or what I've seen most often is it's a physical plus, like an eek G and stress test. Everybody just gets an EK, G and stress test. And if you think about it, that's probably because the vast majority of people that were getting executive physicals for a long time. Were older males who were stressed and maybe drinking too much. Like the stereotype of a executive is probably what drove what those services were. Have you ever seen an executive physical that advertise in menopause care? Anything relating to women? I have not seen that, although I haven't looked into it recently, I will admit. I think executive physicals are inherently closest and elitist and honestly. From a historical perspective, probably also a little bit sexist. I think what really gets under my skin about the idea of an executive physical is this it ha there's this underlying implication that what we do for everyone else, like for the plebeian masses, is crap. It's just that's the bare minimum, but then if you're an executive, you get, you, you get all of these other things. And so the underlying as assumption is we, we don't do all those other things on other people just because they cost money and they're expensive. And if money were no object, we would be ordering all these things on all these people. And so I think that perpetuates this perception. People have that, oh, my doctor won't give me the mammogram when I'm 30 because they're. Or like they're just trying to save money or my stupid insurance doesn't cover it. And you and I know that, the reason we don't do, EKGs on everybody is because they're not indicated. And the reason we don't do mammograms on younger women is because the likelihood of, getting a false positive or of, the risks of the procedure itself. Don't outweigh the benefit or the potential of finding something that we can actually intervene upon and affect outcomes, right? So it just perpetuates this idea that we're gatekeeping these services that all these people could benefit from, but we're just cheap. And so we don't do them on people, and I think that notion is so dangerous and is something that is growing as an idea right now. And I just think the more we can do to. Stand firm against that and be like, no. There, there are indications to do certain tests and certain, interventions on people. And good medicine means that we do things when they're indicated, not just on a whim or when we feel like it. And so I. I just, the whole idea of executive physicals, just doesn't really jive with me. I, you'll see in my website, in all my Micropractice mama materials on this podcast, I really don't use words like exclusive premium elite executive. That's not a. A positioning or a vibe that I particularly wanna go with. I do, I do talk about trying to maybe elevate the primary care experience and create a different experience and have it feel more like self-care. It's not that I'm totally not saying any of those things, but. I think when you get into that like luxury exclusivity tone, you're going to a different place that feels more like traditional concierge and just for the top 1%. And to me, one of the best things about DPC is that it represents this democratization of. Concierge style medicine, it's concierge style medicine made transparent and simple and accessible to more people. And I think it's really about, doing good medicine in this personal, simplified way without all the bells and whistles. And again, the bar is so low that to give someone a concierge style of experience, all you have to do. Is just not rush them and be available to them, answer their follow-up questions. And so there's really no need to add on all these things. And the more of us that do that and say, oh yeah, you can get a Peru scan, you can get gallery testing and you can do that. The more, again, we perpetuate this idea that more is always better and that if you have money, you can get all these things. And if you don't have money, there, you're screwed and you're just, the going to the bare minimum physical with your PCP, that's just a bunch of trash and you're not getting any, like I. I don't wanna give that impression either, I do not use the phrase executive physical. I don't like the phrase, that's not to say you can't have some sort of offering that is, an enhanced version of a physical, but I just, I don't like what it stands for, and I feel like it's not aligned with my own values, so I don't use that phrasing. So that brings me to the end of this Q and a episode that was longer than I thought when I started. I was like, oh, I only have six or seven questions. That's gonna be so quick, but. That brings us to the end of the episode. I hope you enjoyed if you have more Q and As, feel free to send them my way.'cause I'll try to do one of these periodically and that way I can answer more of your questions and the information I share here can be more relevant for more of you. Friendly reminder that I am doing my next webinar on September 10th 8:00 PM via Zoom. I think that is a Wednesday. It is free, no strings attached. I'm gonna put the registration link in the show notes. The topic is going to be making the leap deciding whether Micropractice is right for you. I'm gonna go through the model my secret sauce, the thing that I think differentiates the practices that I have helped mentor as opposed to other dps. See my flavor of micropractice and direct care and I will be answering Q and as there as well. So if you have any other burning questions, show up to that and ask it live. And that's it. I'll talk to you guys next week.