Dr. T  0:01  
Owners of a direct care practice are more likely to experience higher job satisfaction than the insurance based practice. And it's no wonder why direct care is independent of insurance. Patients pay the doctor directly for their expertise. The doctor gets full autonomy in how they care for patients and how they get paid. We've chosen this path for the love of medicine. This is the direct care way. 

Dr. T  0:26  
By listening to this podcast, you may even start to believe you too can have a successful direct care practice. Come listen with an open mind. As I share my personal journey on how I pivoted from an insurance based practice to direct care right in the middle of a pandemic, and the valuable lessons along the way. This podcast may be the very thing you need to revitalize your medical practice. I'm your host owner of a direct care podiatry practice. Dr. Tea Nguyen.

Dr. T  0:55  
this is another special episode because I have the amazing Dr. Diana Girnita, who is a specialist she's a rheumatologist. And is actually one of the early people I reached out to when I first heard about direct care just two, two and a half years ago now. The idea of becoming less dependent on insurance reimbursement was really foreign to me at the time. I had first heard about Dr. Girnita on my DPC story.com. I will attach the episode link down below in the show notes. And then I saw her again over and over again on Facebook, she created the specialist for direct care, a private member group for specialists because there wasn't a unifying professional Alliance at the time. And she has created incredible value to the members, a lot of great connections. I've made a lot of great friends in that network, including Dr. Grenada. And she's doing so much more than that. She's recognized the need to have a professional entity that provides a centralized place for specialists. To get that community support and the tools we need to develop a direct specialty care practice, you'll see that there are shared beliefs between DPC direct primary care, and DSC direct specialty care. But there is an important difference for specialists. And what I learned along the way was that we have a smaller pool of patients to serve. And therefore our prices must reflect our specialized expertise. So they're generally going to be a smidge more or higher than a generalist. That's just how it goes. So needless to say, Dr. Girnita is well connected. She is at the forefront of DSC, and has a wealth of knowledge as it pertains to the direct specialty care movement. So I brought her here today to pick her brain. So why I chose Dr. Girnita, besides the fact that I love her very, very much is that I want her to share this space with us and vice versa. I love learning from other specialists. And I believe that idea is not just inventing the wheel again. But it's rather the crossroads of different disciplines, so different specialists, not just podiatry, not just surgeons, everything else that comes in between business and in this instance, even a rheumatologist so like always, I say life is a buffet, you can pick and choose what will satiate your appetite. And that also means don't knock it till you try it. Welcome Dr. Girnita,

Dr. Girnita  3:31  
thank you so much. This is lovely introduction. I don't know if I deserve all of that. But I appreciate the fact that we come together as specialists to help each other, but also help others that have a huge interest in changing, changing the way they interact with patients. They don't change none of us, we change our way of practicing, we probably have a little bit more time to practice in a different environment. But it changed the way that we interact with patients, we give respect to the patient. And we request the same respect back to us. I want to thank you for inviting me and I want to thank you for taking the lead to present to the world that direct care is a possibility. And for those patients that do not know that they can purchase their medical services, you were one of the first people that I've seen very vocal about offering options to patients and I'm very, very happy to connect with you, as well as others that are interested in direct care.

Dr. T  4:45  
And I can already see that exponential growth of interest and active people pivoting out of the insurance based practice into direct care. So I wanted to know from you directly. How did you find yourself moving Adam, the insurance space dependent model, and into direct care, like take us from where you started to where you are even now?

Dr. Girnita  5:08  
Sure. Unlike other people, I started cold turkey. I was in traditional practice. And when I decided to start my own company, I also thought about how can I deliver medical care in an easier way, in a transparent way, and also making it affordable for patients. I had a couple of experiences with patients that will come to me, after they were seeing me in the traditional private practice, you know, patients that were carrying a high deductible, they brought me a bill after my first consultation of about $4,000. And of course, I didn't charge those money. And of course, that was not the cost of my consultation. Actually, I have to tell you that I had not even known, you know, I didn't even know, what was the cost of my consultation, I was not able to see what is my value in terms of the services that I provide? Because no one ever discuss with me, what is the cost of my consultation. And, you know, after I was seeing those bills, I quickly understood that that's not what I received for, you know, an hour of consultations. And I tried to help the patients and trying to cross those barriers, where you find out why the patient was charged so much, it was almost impossible, because it was like a wall that you could not crossed. And that was on, that seems to be unfair to me, because I wasn't there to hurt the patient, financially. And although I was able to help medically, financially, the patient will hurt a lot. So I thought about the the country where I came from, where we had two systems, one was the, you know, the private system, and the other one was the public system. And I remember that in the private system, when you want to get something, you go there and you find out the door, or the timer was at the door, you find all the prices for everything for the consultation for the laboratory workup for an MRI, or a CAT scan, or an ultrasound. So if you wanted a service, you were able to find out and then discuss with the doctor that you saw what is most appropriate for your for your medical needs to get first. And I wonder myself why can we not do that here? Why is it so complicated for us as physicians to know how much is the cost of our consultation, or how much is the cost of a test that I ordered. And that's how I started to investigate. And I was fortunate to know about direct primary care from another colleague of mine that actually soon after residency in internal medicine residency, she went into direct primary care. And I seen her I think she was in I mean, I have to retract that. I think she worked for a traditional practice for a few years. And then after she transitioned into direct primary care, and I remember her story, and how she was telling me that she can provide the cost of her consultation, and she can provide the cost of the labs. And the prices that she described to me were ridiculously low compared with what I knew what I was able to figure out in terms of my workup. And that's how I started. And on the way of me building up my practice, I met another good friend, and today is a mentor for me, Dr. Floss bowler, who also was very supportive of a specialist going into direct care. And at that time, I had no idea that in the United States might be others like me, I knew about direct primary care, but regarding specialists, everybody that I talked to, they were telling me that as a specialist, you're not gonna be able to survive without the referral system to back you up. And that was the scariest thing ever. Because when I stepped into private practice, in direct care, there was no one that will refer me patients no system to refer me patients. And it took me a while to understand where the patients are coming from or how the patients are getting to us.

Dr. T  9:59  
I really will I love that you talked about the referral source because I don't think that was I don't think we really understand it as a specialist that we did for a long time rely on that referral pattern through the gatekeeper. And now that you mentioned that I remember vividly in one of the textbooks in medical school, when we were being trained in podiatry, there was this picture that says, it's the PCP that is the gatekeeper for what patients have access to. And so branching out indirect care, that means we are directly marketing to people, the consumer, without interference without a barrier. And I think that's really important to know that, even though that's how we were taught, we see in direct care, that this day and age with the internet with a lot of resources at hand, you can market directly to consumers,

Dr. Girnita  10:51  
yes, US physicians were very reluctant to this idea. We are very reluctant to put our face out there, and you know, promote our services, we are actually also afraid that we'll be liable for something that we say or something that we do. And we are afraid that we're going to ruin our reputation being online, or being you know, more visible or writing blogs or, you know, trying to help people. Actually, I did find out like you that for us in the right care, there is no need for patients to be referred to us. In our days, patients are very smart consumers. And they know exactly how to pick up a product or a service based on the research that they make. And there are more and more patients that understand the value of the right care. And not only that, but the price that they had to pay for a service. In the traditional system. Even today, when we have an active law of transparency, we don't see the prices of services of medical services that are predictable. I'm not talking about catastrophic care. I'm talking about medical services, laboratory services, imaging services, we do not see the prices listed on on the websites of the hospitals or clinics that practice traditional medicine, what we find, if we do find is a tool to estimate care. And if you want to find more, you're not going to find the right price, you're not going to have the direct price, which you will get from a direct care specialist, or a direct care podiatrist or direct care, primary care physician, you're not going to have surprise bills from us. And that is something that patients appreciate very much. Because when you go to buy a car, you want to know exactly how much you're going to pay for that car. When you go to, you know, let's say have a steak, you're not going to order the most expensive steak, if you know you're not able to afford it, or the most expensive bottle of wine, if you're not aware about the cost of that.

Dr. T  13:21  
But you might order it if somebody else was going to pay for it. And therefore that's how we hyper inflate the cost of thing in our system, people don't really know

Dr. Girnita  13:31  
exactly. But then even in the traditional system, when you order things, you know, you're going to pay for them, sooner or later, you're going to pay for them, and you're going to pay so much that is going to burn you financially. Because when you go to the emergency room, you get your your good, you know patient, you pay your co payment, you know, and then a month later you're gonna get a bill from the ER, two months later, you're gonna get a bill from the radiology department. And then three months later, you're gonna get a bill from, I don't know, anesthesiology, if you had certain procedures. So in a matter of six months, you're gonna pay so much more for that. Then if you paid if you exactly knew what you're getting. So patients were deconditioned in time to believe that they can get access to medical care only through their insurance card. And that needs to change. Because, you know, as we see there are more and more players coming along to offer the right care and transparent prices. And that's normal for any industry. There is no other industry where so many things are hidden like in our industry like in the medical industry, but we doctors, we don't have that interest. And we are not part of deciding that Mecca As in the traditional system, we're a part of that discussion. When you step out, and you do your own clinic and you do your own contracts, and you serve the patient directly, at that point, you are in charge. And you decide your value. And you decide what you can offer to the patient, and the patient decides if he wants to buy that service. And if he's happy to, because if you provide a good service, the patients will go and spread the word and spread, spread to others, you it's like organic growth. And that will reflect to you to your brand. But when you are part of a big system, as a physician, the patient can say everything about that system. But it will affect you also. And you are basically branding the system, you don't brand yourself,

Dr. T  15:53  
I love what you have to say about the problem with price, lack of price transparency. And people just can't grasp the idea that because they don't know, it's that's why it's hyper inflated. That's why a hospital can bill out $23,000 For a surgical procedure that a surgeon can do easily for $5,000 elsewhere. That's why we have to really push for price transparency one way or another. But I really wanted to dive deep into how you made the decision, the mental obstacles you might have been through when you first learned about the option of not being insurance dependent. I can't imagine that being an easy thing for most people, because we all were conditioned to not know the price of things, not know our own value not know how to speak to patients about marketing about the solutions that we provide, like, what Where did you find some of the hiccups early on where you said, I'm not so sure I want to do this, or were you all in immediately,

Dr. Girnita  16:55  
I had many, many moments that I wanted to turn back and accepting insurance because it was hard, it was hard to, you know, tell myself that I have a value. And it was hard to tell myself that I have something to offer to patients I knew, but to tell the patients that I have something to, to offer, it was so hard for me. And then as a physician, you come into this world, and I'm gonna tell you that I came to this world, the medical world, without having anybody in my family being as a physician, I wanted to be a physician, I desperately worked hard to get to be a physician. You know, this is my nature, this is my passion. I love taking care of patients. But I also have to leave, you know, I have a family, I have three kids. And it is very hard when you cut the strings with the big system. And you cut your salary from, you know, a good salary to zero. And it is hard. But every single time I had people like you, or like my mentor that they said, now you're doing a good thing, you're doing the right thing. And even my husband was supportive. My kids were supportive. You know, they told me many times we admire what you're doing, we know that you tried to do the right thing. And just looking around and then seeing patients that were coming back to me, that was very reassuring that I'm doing the right choice. Luckily, I never had a patient that complaint. I never had I had patients that they didn't pay me, you know, they disappeared, I really thought that it's the right thing for me. But on the other hand, I always told myself that those are isolated cases. And what I do and what I provide to patience is, you know, from the bottom of my heart, I do the best that I can for every single one. And there is not a single one that is more important than the other one, I really want every single one to be better, to get the best that I can give and with the support of people around me and other specialists that I've seen, and I discovered that they are doing the same. And I did find some people that were doing this for years, like 10 years, or 15 years. And I said to myself, you know, if those people were able to survive 10 years without taking insurance, why not me? Why I'm not able I know it's gonna be a process. It's gonna take time, but I remain positive that, you know, things will turn around. And it did.

Dr. T  19:43  
Yeah, there's a lot of deep reflection. I have the same parts of myself as I was transitioning out, you know, some days My husband actually because he's still He's an associate he's employed. He's very comfortable. He loves the way his model is. And he gives that to me. On several occasions, why don't you just go back to insurance. And it's really for me, that hurts my ego, because I made it a point to say, I'm not doing this because it was so painful to do it, then I'm going to choose a different kind of pain. And that pain looks like being naive. It looks like starting something new with the potential of failing, because I am doing something new. But I would much prefer that pain than the pain of doing what everyone else is doing. And when you do that, you can't cycle yourself out. If you go back into the system that is breaking you guess what's gonna happen, you might be dead, you might either go into a deep depression, we have high rates of physician suicide because of the system, because they don't feel like there's a way out. And so I kind of hated it when he said that to me, like, why don't you just go back to insurance. He didn't say it to be mean. He didn't say it for any other read it. He has good intentions with what he said, Because he saw how hard it is to build a business. And anyone who builds a business knows how difficult the ups and downs are, it's not always up. But it's always not down, there was something that you said that I think is really important to point out is that we do produce a lot of high quality care, and patients are very satisfied with that. But no matter what model we have, there will always be a percentage of people who are going to be dissatisfied with whatever we do or don't do. So there's an acceptable rate of dissatisfaction in both models. But I find the indirect care, the rate is much lower. It's kind of like saying to a surgeon, you'll always encounter a complication after surgery. Well, of course, it's a numbers game, you do 100 surgeries, hopefully you don't have 100 complications, hopefully it's like 10 or less. So there is an acceptable amount of negative versus the positive. Now in the insurance based practice, I wonder if you remember what life was like for you, back then the quality of care you were delivering the time you were spending with patients, the feedback you got from patients, how has that been different now that you're in direct care,

Dr. Girnita  22:10  
I think the most important thing that I discovered during direct care is that I have time with the patient. And time is value. And the other thing that I discover in direct care is that I have direct communication with the patient, which did not happen in the traditional system, although the patient will send you a message, that message gets filtered three or four times before it gets to you in the traditional model, indirect care, the message gets to you, you can pick up the phone and call the patient right away. Or you can answer the message right away and the patient feels heard. And the patient feels like its problem is solved. It's taken care of they don't wait 24 hours or 48 hours or a week to get the answer. They get the answer very quickly. And that direct communication, patients wants to call their doctor, they don't want to stay on the phone for 30 minutes for someone to answer. And then you know, in the middle of the conversation, the phone call gets dropped. And then they call again, they wait another 30 minutes to get to the doctor and then they don't get to the doctor. And then guess what they get frustrated with the doctor's office. So they're going to use the name of the doctor for all this, you know, all these hiccups that are happening between him and the doctor. He's going to say doctor, so and so office, but his doctor so and so the doctor's name is the image of that office didn't solve his problem, this thing doesn't happen in direct care. And then the time is value. I also thought that giving time to patients to explain their situation, it's so important for you as a physician to understand exactly what the patient comes through. And what is your role there. When you have a visit a new visit of 12 minutes you barely understand what's going on with the patient. And in those 12 minutes, you try to put I don't know in my specialty 20 orders more there's something the pharmacy and then tell patients what they have to do. And then you hope that they take that and they're going to do it and they come to you confused. And they leave from there even more confused with names that they don't understand medications or lab work they don't understand. And guess what they go on Google on Dr. Famous Dr. Google, and then they discover the worst of the worst. So when you take the time and explain to them, you know, not only hear them, but also explain to them, This is what I want or this this is what I'm thinking about. This is my process of thinking. patients appreciate that. And they don't have to call Dr. Google.

Dr. T  24:50  
So say that I think about who I was when I was a resident. When I had to report to my attending it was matter of fact this patient comes in with these problems that are not his matrix. and plans. And I find that we do the exact same things straight into our practice, not realizing that what you're saying isn't sticking, because we're not speaking the patient's language, we're not there, they don't have a medical background to know what you're saying the terminologies you're using, or even the speed that you're saying it out to them, it's just mumbo jumbo. So to do that in seven to 12 minutes, it's highly ineffective, they get confused, to get mad at you the treatment regimen is wrong, they take the wrong amount of medications, all of that is very, very harmful. So I think there's a huge part if even if residents don't learn about direct care, they still need to learn about the way we communicate. But how do we do that in a system that keeps trying to squeeze us out more and more time from patients. So now we have to go through things really fast, or we only treat one problem per visit. And now, now that one hour that should have been an hour is five appointments, wasted time, time off, that needs to be requested? Driving gas prices are incredibly crazy, right now, everyone's time is wasted in the person's problem is still not solved. How frustrating. So I wanted to kind of pivot into what what do you think you would share with somebody? Because it's obvious that the system is broken? But what would you say to somebody who is just kind of on the fence about starting to opt out of insurances? What would you say to that person?

Dr. Girnita  26:26  
So first of all, I think it's important for us, physicians to understand that we have value, and patients need our expertise, and you will be able to offer your expertise to patients without the help of someone to back you up, that's the most important thing, I'm not going to say it's easy to step out of the insurance system and start a direct care practice right away. There are many people that do hybrid practices. And that's a viable solution. You have to decide what is best for you. And what will, you know, bring you comfort, mentally, financially. And it is also important to understand that what applies to my specialty might not apply to your specialty, and every single one of us, we know what we are good at, you know, we can find our niche, our expertise might be unique to you, or to your education to your experience. And you should use that to build up your reputation. The other thing that I learned is that you should start branding yourself early on, you should be proud of what you have done and brand yourself early on, it took me a long time to understand that that's important for us, I was very, very hesitant to get on social media. And even today, I'm not very active on social media, and, you know, seeing others, I was like, I cannot do this. But then I understood there is there is so much need for you to be in connection with your patients to put the word out there, work on your brand, develop something and get recognition for the work that you put in. This is something that we you know, we a physician, we as physicians, we don't have that kind of training or that mentality, I would say,

Dr. T  28:24  
yeah, yeah, those are, those are really important considerations. So I know I, I basically boast about the lovely side of direct care, but I also want to be very real about it, it is a new venture, it is a new thing to do, which means there's going to be a growth phase and you do have to persist. So really, direct care is not for everyone, it's more for somebody who is a little bit of a risk taker who sees a bigger vision behind the day to day, kind of mundane administrative things we have to do like the social media stuff, the branding part, like all of that is painful for most of us. But at the end of the day, the way I see it is if we want true freedom in the way we practice, we have to front load the hard work. And the reason it feels hard is because we never did it. But just like any other procedure or any other way of managing a patient, it's weird in the beginning, but then you get used to it and then all of a sudden the rest of your career. 1015 20 years down the road, you're completely independent. And so I invite all the listeners to just think of your future in mind as you're doing these, you know, early stage things that could be painful, or really try to enjoy some of it. Because you are building you're building something really wonderful. We're in the forefront of this. It's really exciting to be here. And I wanted to ask you this. This is a question that I hear other people asking all the time and I wanted to know what is the 90 year old version of you saying to yourself right now.

Dr. Girnita  29:58  
Oh my god, I never That's so far out,

Dr. T  30:02  
you got me because I can barely think about what's for dinner, but we're gonna push forward on 90,

Dr. Girnita  30:08  
I think I would look to 270. But I would, I would love to look back and say, Okay, I build something, I built a legacy, I was able to help others. And I get recognition for that, I think there is nothing more important than building an empire, you know, then people are remembering you for the work that you have put into them. And, you know, everybody remembers Steve Jobs, right. And everybody talks about Steve Jobs. And, you know, when I read the book about him, and what he said that those that are crazy enough to think that they will change the world, those will be the ones that will change it, I think that's very true. But not only that, they created an empire, and they, you know, created value for other people around them. But they are remembered for what they have created the value that they created the you know, not only the money that they brought in, but also about the value that they left behind what will be my work today without Steve Jobs, I think that if you look back, you should appreciate not only the money that you you create, but also the work that you put into others, I have people that I brought into rheumatology, I brought them into rheumatology fellowships, I'm so proud of them. But they're also recognized my work with them. The same was the direct specialists. I invested so much time in other people. And I tried to help as much as I could, you know, with an advice and answer right away, so many specialists. And when I saw the need, and the interest, at that point, I created that specialist for direct care group, where people can come connect, help each other, show that they are colleagues and show that they are part of a tribe, but have that feeling that they they are there with the tribe, but they are there to contribute as well. And then we took this to the next level. And we created this direct Specialty Care Alliance with the same scope to you know, kind of come together, help each other, grow each other, empower each other and exist in a space that is considered new. I don't think it's new, I think it's an alternative to the traditional system. But at least you don't feel alone because when I started, I felt so alone, I had no idea where to find another specialist like me, if I had a question, you know, I had to talk to so many people that will not know what I'm talking about. And that that kind of need, I think we filled in the last almost three years,

Dr. T  32:59  
I totally get that. I as a podiatrist because our specialty is even smaller, I often feel alone, I almost feel like that's like my my motor. That's just who I am. Now I'm just alone writer. So you know it, sometimes it's great. And other times, it's like I wish I had a better idea or a better tangible visual of what could be. And so that's kind of why I created this podcast so that there is something tangible, somebody can listen to pull up an episode and say, I'm having a bad day, I kind of need a motivation, I kind of need a push. Because we're human, we are bound to feel terrible about ourselves. Because we're telling ourselves these stories that don't have to be true. And we soak in our aloneness. But in reality, in the grand scheme of things, your 10 year old version is probably really proud of you is probably saying, Oh, no way. Like no i did i do all those things.

Dr. Girnita  33:54  
Yes. So I want to encourage people to think about that. When I started. You know, I had no idea about any rheumatologist doing that we are three I'm three years into that. And I empowered to others to come to the to the field of rheumatologist to others that I know that they reach out to me that we discussed and then I, you know, I was able to help them a little bit to empower them to stop. And that makes me so happy. Because those people, they understand that they have someone in the field, they have someone that knows what you know, they are doing. And this is very important for us to know and help each other. Because, you know, I'm you know, I'm no competition to them because they are not competition to me. But we can help each other and how you can help patients as well. You know, if I have a patient in a state where I'm not licensed, I'm going to send it to them, because I know they're doing the right thing for the patient. And that's what I want to create was this network of specialist in direct care if a patient finds finds me, but I cannot serve Him. I want to know who to send that patient. And that happened to me many times, I had to research the internet to find the cardiologist or to find the nephrologist for the patient. And I've done that with pleasure, because I know that patient was desperate to find someone. And, you know, I had a few patients that they call me back and say, hey, you know, you send me to that doctor, and I am so appreciative that you did the work for me, I could never found that doctor without you. So that kind of, you know, story from patients made me take this workload, to find this specialist or to promote this movement and to grow into his movement, to help other specialists to be direct care, or be in direct care, and eventually help each other but also help patients

Dr. T  35:56  
I hate to have to end it here. And you know, I'm always in your DMS, I'm always asking you questions that are usually not related to direct care, but it's just like, I need to pick me up. And I appreciate how thoughtful and gracious you've been with your time to answer those questions for me, just to give me some reassurance that this is this is indeed, the right path. And sometimes the right path is the hard path. But I know that once we carve ways for future generations, we can look back and say, Well, we did do the right thing. And we are making it easier for those to pass through without the mistakes that perhaps we have. So I want to thank you for taking the time to be here with me and the listeners. Do you have any last minute sage advice for anyone who's listening who might be interested in direct care,

Dr. Girnita  36:46  
my advice is to come to the tribe, I would say come to your tribe. Or if you're not ready, just come to learn from us, it's very important to have the resources ready and have ideas. And then you can build your own dreams, you can do the practice that you dream for Be Your Own Boss, I think there is nothing better than being your own boss. It is not easy, but there is no better feeling that you will have, at the end of the day when you say I did the right thing. And I did it because I wanted to do it. And nobody told me how to do things and in what frame time, and for how much money and for how long. And that is very important for physicians to understand that they have the value, and they create the value of the system. They are the meat of the system. But we have to remind ourselves that we are there as a valuable, you know, we'll have the system.

Dr. T  37:48  
Well there you have it, that direct care way is really your way. So I hope you found some value bombs here. Please do share this episode with a friend who is fed up with a traditional insurance based practice of medicine with conventional thinking the person who's sick and tired of being sick and tired, and someone who deserves a practice that they love. I would appreciate that so much. And you may never know if they're just one episode away from a totally different life. I'll catch you next week. Take care.

Dr. T  38:20  
Thank you so much for being here with me today. If you enjoyed this episode and want to hear more, please like, share and subscribe so more people like you can have access to another way of practicing medicine, that direct care way. Let's connect by my info in the show notes and send me your questions. It might be the topic for future episodes. 

Dr. T  38:40  
And lastly, if you remember nothing else, remember this. You are in control of your life. See you next time.