How Direct Care Reduces Burn Out

Dr. T  0:00  
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. They have chosen this path with a love of medicine. This is the direct care way. 

Dr. T  0:24  
By listening to this podcast, you may even start to believe that you too can have a successful direct care practice. Come listen with an open mind as I share my personal journey and how I pivoted from an insurance based practice to direct care right in the middle of the 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  0:53  
Did you know direct care reduces burnout, I'm going to tell you exactly how that works in this model. But first a story 2018 January, I was a few months pregnant. I was working as an associate. And I had a bunch of surgeries scheduled in a system that I was at. There is a surgery scheduler in house, who does the coordinating, including the prior authorizations, the scheduling between my clinic schedule and the surgery schedule. And I had asked her what was going on I saw all my cases canceled. So why didn't anybody tell me I had to check the schedule myself to see that happen. When I asked her she didn't really make eye contact and simply said, I'm just here to do my job, you might want to ask your bosses about that. So I did. And then that's when I realized that no matter what their response was going to be that I was just going to be a replaceable employee. The fact that my schedules, my surgeries that were scheduled was cancelled without notifying me, the surgeon, the person who produces revenue, showed me how little they cared about my contributions. And then that was when I realized I really just had to open my own practice in complete my maternity leave, which was around May at that time. And then I chose not to return. 

Dr. T  2:13  
At that time, I was really motivated. I was definitely uncertain, and definitely not prepared to have my own practice. But I didn't have another choice. I had applied for different jobs. And we have corporate systems out here, there was no match for me. So I had to create my own job. Luckily, I'm resourceful enough to figure out some stuff. And at least enough to get me started, I got to see the back end of how private practices work. And I had a lot of resources to get me going. That's what I did. I recruited consultants, coaches, legal attorneys, and so on, I started the practice with the insurance contracts. Because I thought that's what you're supposed to do. I was on a roll, I got really busy really fast. But I was also seeing a ton of patients, so much so that I wouldn't, I would have a difficult time recognizing people's faces if it wasn't attached to a chart, or if I didn't look at their feet to recognize that I've seen them before. Isn't that crazy. 

Dr. T  3:11  
But that's just how it goes, you know, 2030 day patients seems to be about the average, I've met doctors who see as many as 50 to 60 patients a day. That's insane. But that's the system that we have in the insurance based practice. And instead, what I've done, what I did was traded volume, or value. So instead of having to pack my schedule with a ton of patients spending a few minutes with them, each time giving incomplete care, because we only had the capacity to fix one problem per visit. And if they had multiple problems, it would be multiple visits. And you can see how we're in getting it right. Like I know you're burnt out, I was burnt out and I was only in my first year of practice. So instead of seeing a sleuth of patients, sorry, you might be hearing motorcycles in background, I traded in seeing, let's just say 30 average. In an average day I saw 30 patients, I traded that for direct care model, where I only need to see a handful of patients. 

Dr. T  4:09  
Some days, depending on if I have procedures, or other things that I can offer to patients. Some days, I only need to see one to two patients to make it equivalent to a 30 day patient workload. That's how you didn't reduce burnout, you make more but you work less for that you charge more or you discharged appropriately because the insurance base model undercuts you. You only get a percentage of what you build out. And that's how you save energy and time. Looking back. I had created a practice that pushed people in and out. It was the machine people had insurance. They showed up. I eventually got paid months later, but I didn't see the system really working for like the next 20 years. I didn't like the system. I wasn't happy. I wasn't enjoying what I was doing. I was seeing a bunch of people who would just didn't appreciate that. error that I was giving, or they didn't want to pay more than their copay, or they fought about their copay, they felt very entitled to expert care service, but they weren't going to pay for that. 

Dr. T  5:11  
And then I even had patients who no showed. And that was really frequent. I had a couple of times where I held Saturday in clinic, thinking that I would accommodate people who work and who couldn't take time off during the week, they scheduled back then I didn't have a protocol in place to secure a booking fee. But I scheduled them and they didn't show up. So I spent the whole day with cancellations. But I still had to pay for my, my stats. So all of this accumulated, it was really annoying, it was burning me out. And I didn't know of another option. So what I'm sharing with you today are the symptoms of burnout, not being motivated to care about your work anymore, or you're just emotionally empty. 

Dr. T  5:52  
I had to Google what burnout meant. And the most concise way that it was defined is the emotional, physical and mental exhaustion by excessive and prolonged stress. You may show up as irritable, impatient, lacking energy, maybe it's hard to concentrate, or even care, maybe you become more cynical, and you're questioning why you even are doing what you're doing. You question the whole system of medicine, and maybe you're even looking to exit entirely. And I've met a lot of people who have told me, I think I'm burned out, or they tell me the symptoms, and I have to tell them, this sounds like burnout. A lot of us don't even know how to label burnout, which is filled this complete lack of joy in the work that we do. 

Dr. T  6:41  
We used to enjoy it. But now the system has made it really impossible to live a balanced healthy life. In this type of practice, I'm really passionate about talking about direct care, because I can see it as a way out of that burnout of that system, physicians tend to experience a high rate of burnout, because that's how we're conditioned, we've been conditioned to accept certain things. And at times, we feel like it's out of our control people who tend to go into medicine, how the idea of helping others, right. That's why we sacrifice a decade to learn medicine. That's why we take a financial risk the loans to get that education. And we also miss out on a lot of personal events. So we're used to sacrificing, we're used to delayed gratifications. 

Dr. T  7:26  
And then when we enter a system that knows that and don't see a lot of pushback for that, they exploit us, they continue to come at us with really low reimbursement rates, which continue to say low, because there are doctors who are saying, It's okay, it's fine, we'll take this rate, we'll just contract it, it's now become the way of life the way of medicine to work hard to get paid. Well, all the stories that we tell ourselves, we tell ourselves, we'll just find another way to make the revenue work, right, we get resourceful, we get really creative, we invest in more technology to make up for that income that we need to have to make the business sustainable, and then suddenly retired. So we're used to doing things for others, we're really used to not causing any trouble, because that could mean losing your stable job. Or for me, long time ago, I was at risk for losing my residency position. And in residency, I had already accumulated a six figure debt. And that was a huge risk for me to speak my opinion, to speak out to some of the injustices that was happening to me in the program in the system. And most people will not take the risk to speak out when they see something wrong, because they don't want to lose that position. It was a really, this is how we're conditioned right happens in the workforce, too. 

Dr. T  8:42  
You buy a house, you take on more loans, you have these financial obligations, you get married, you want to pay back your debt. So we cannot take a risk of financial risk on jumping ship from the insurance base model into direct care or even speaking out if it means losing our job security. That's why there's only 1% of direct care doctors, this stuff is really hard. It's really hard to let go of an identity that we've worked so hard to get only to realize that it's not working for us. This is why I'm really dedicated to working with physicians who are experiencing burnout in the insurance based model and helping them see a way out. And I'm here as a recovering insurance based author sharing with you that burnout is at an all time high because of the system. There's nothing wrong with you, you might say that you're a people pleaser. 

Dr. T  9:28  
And that's the reason why you're burned out. But this is not a character flaw that can't be fixed. This is just a circumstantial problem that can be fixed by changing your circumstances. Other things that are making physicians really vulnerable is that we care about online reviews. So online reviews are being weaponized for patients to use that against us when they want something you know, maybe they want another prescription and another narcotic or this or they're that in, it's not appropriate, but they go against you and say Well, if you don't do this, then I'm just gonna write you a negative review. And then we feel like crap, because we've worked so hard to help people. And this is how people treat us. 

Dr. T  10:09  
And then you multiply that by 30 to 60 people in a day, which is the usual schedule for an insurance based doctor, and then you don't know what else to do. You feel really hopeless. At some point, though, we need to recognize that we are burning out we need to name it, say it as it is, you say that I am burning out, I feel burned out. And then we start digging into the source of that problem so that it could be addressed all of the calls that I've done with other physicians who have heard about direct care, they all say they know it's the system that is causing burnout, but they don't know what else to do, and they don't know how to get out of that system. If you watch the matrix, the old school movie, Morpheus said this quote has always stuck with me, it goes like this, the very minds of the people we are trying to save are part of the system. And that makes them our enemy, you have to understand most of these people are not ready to be unplugged. Many of them are so inured, so hopelessly dependent on the system, that they will fight to protect it. 

Dr. T  11:15  
Most of us in the insurance based system believe that that was the only way until it wasn't right, we fought for that we wanted that we felt that it was the right thing to do that we had to work hard to make money, that we had to see a lot of people to justify our income. And I'm telling you, this is all a mindset, none of that has to be true. You can make more money and work less, you can see one patient that equals 30, you can start identifying the things that are burning you out and then creating a plan to get out of it. It won't be easy, it won't be overnight. But that's what I'm here for. And speaking with a lot of doctors, this is what I have to share for you today. 

Dr. T  11:51  
The four things that will help you through those stages of burnout, and how to start exiting out of the system. Number one is establishing healthy boundaries. And that means saying no to stuff that you don't want to do, or doesn't give you anything back in return in the way of happiness, money or opportunities. When you're in direct care, you're going to be saying no, to free work more often. Because now you know your value. And you're going to choose to only work with people who value you, maybe you're still in the insurance base system. And you're wondering how you can create healthy boundaries right now, as you make the transition into opting out of the worst payers. 

Dr. T  12:36  
So what that would look like is you looking into your insurance contracts, seeing who's giving you the most headaches are the least pay and consider dropping them. If you want to try to negotiate through an intermediary or a system that can help you negotiate a higher rate, you can certainly do that. But again, you are maintaining the system, and the system or the house will always win. So recognizing if having unhealthy boundaries is part of the burnout, where you're doing a lot of free work, uncompensated work after our work, it is time to look back and start saying no to some of those things. Like if somebody asks you can you see another patient on your schedule that's already full, you can start saying no, after all, you have a bucket of energy. And if it's depleted, it's depleted. If your phone is out of batteries, you can't just try to revive it, you actually have to stop and charge the phone for it to work again, you are the same thing you need rest, need space, need peace. 

Dr. T  13:33  
So make sure you start establishing healthy boundaries and sticking to it. Number two, in reducing burnout, raise your rates, the point of opting out is to reclaim your freedom so that you're not tethered down to a full booked out schedule where each encounter pays you so little, and your energy bucket never gets restored. Contrary to that if you see fewer patients, but you focus more on them individually, where you don't have to overbook and you are charging appropriately for your skill set. That is how you get your energy and your time back. Money is just a tool, it's not a bad thing. It's not a good thing. Money is a tool that can buy you time and energy. Therefore raising your prices does help prevent burnout, because now you're not chasing every single dollar or every single patient who wants to come in who may or may not want to even pay their copay. 

Dr. T  14:23  
This is the mindset that you'll develop, you're no longer going to be scrapping along for any patient. With any insurance, you're going to be a lot more selective and you're going to be selective in the way of what makes financial sense for your patients. If they want your service they have to pay just like any other service industry. Number three, making CEO decisions. owning a business is really hard. I don't know about you, but I never had a class on owning a business. But there is a difference in the mentality of the employee, one who just shows up and is told what to do versus the CEO of the business who makes business decision Is that are often hard, the decisions are intended for the greater good, it's not for you, the individual to please one individual employee, it's for the greater good of the business. That means you will have to make difficult decisions in regards to who to hire, who to fire, what contracts, you want to participate with the details of who works with you on your team. 

Dr. T  15:23  
All of that are decisions that CEOs have to make. So when you're confronted with a difficult decision, such as Should I raise my prices, you need to move away from how you feel about that, and where the CEO hat, and you're going to ask yourself, what would the CEO of this business do in order for it to be profitable. And for it to work, I often get doctors who have huge resistance to changing their prices, because they have an emotional attachment to that price. But as you know, the CEO of any business industry, you name it, somebody had to make the difficult decision to tell their stakeholders, their patients or clients that prices are changing, that is congruent with inflation. It just saw an article from the AMA that showed a graph demonstrating how Medicare reimbursement rates are not caught up to inflation. 

Dr. T  16:13  
Meanwhile, the cost of technology, the cost of retaining an employee or the raises that they expect, in a job, those go up, even our rent goes up, right. So making sure that you're making decisions as a CEO, detached from how you feel, but making decisions for the greater good, which is going to be healthy for your sanity, and your longevity. And then number four, you might be in a situation where you need to enlist a professional, it might be a therapist, it might be a business coach, you just have to get outside of your mind sometimes and get a third party to help you navigate through your own emotion through your own history, to your hardwire beliefs that is holding you back from having what you truly desire. You really have to look at this as an investment in your health and your well being. And it's not because you are broken, there's nothing broken about you. If you find yourself talking to yourself saying I'm just broken. That's just how I am. I'm a people pleaser. That is just a belief. That is a story you've been telling yourself over and over again, that isn't true. It's just a thought. So you have to work on those thoughts. 

Dr. T  17:16  
And sometimes you need to enlist a professional to help you with that. Let me give you an example of stuff that I encounter all the time. I'm actively on LinkedIn, and Instagram. And I always get private message from a business from people I don't know, who says I like your stuff, can I pick your brain? What I have to do for myself is ask, Do I even have time to help this person? Do I like this conversation? Do I like the opportunities that might come from it? Have I given this talk multiple times in the past? Because if I did, can I be more efficient and just direct them to let's say, a podcast? Or a really low cost course both of what I have now, if I say yes, what does that do for me? If I say yes to one thing, what am I saying no to Will that be detrimental? There's only 24 hours in a day. And my energy bucket is very limited. I naturally have low blood pressure, I have to push myself to be out there. That's a lot of work already. 

Dr. T  18:13  
As an introvert. Although I love helping people and giving value and making their day a little bit brighter. There comes a point where I can't keep doing this for free. If you say yes to this type of free stuff that people ask of you think about what it can do for you, right? Can you create an asset out of it? Or have a developing working relationship? Or is this just a one sided? Can I pick your brain because it's free. I've gotten to the point where I realize I'm at my midlife, and I don't have free to give anymore, I have a limited amount of free. What I really want is freedom. But I can't get freedom. If I keep doing stuff for free. That isn't rewarding. That just ends up burning me out. So now what I do in those types of situations, I'm very polite. I'll answer one or two questions quickly. And then I'll redirect you to my website, you can learn more, if you listen to my podcasts, you can schedule a one to one if you're serious, or you can pay for my time, because the people that I truly want to work with will commit time that's undistracted to take that one to one call. And if they want to work more with me, I give them the opportunity to do so. And they can pay me for my hourly rate. I love that type of relationship. It's giving on both sides. 

Dr. T  19:21  
And that has been the most fulfilling thing I've done in my coaching business and in my private practice. So this is your invitation to start saying no, but with purpose. You're not saying no to be mean or to be callous or to get people to hate you. You're just developing a muscle that probably needs a little bit more development on and sometimes it does hurt but just like any pain, it will callus over time. If you continue to do it realizing you're doing it with intent. You don't even have to explain to people why you're saying no. You can be very vague and say I'm over committed or here's my hourly rate. You can set up a free Calendly link Calendly I can't pronounce concept, but I'll put it in the show notes, create a free link where you can attach a payment system with. So once they make the payment, you both committed, it's a perfect working relationship. 

Dr. T  20:10  
One that I promote physicians start moving forward in. Because we as a collective, the more work we do for free, the more people are going to expect it. And then we're back into the system that exploits our free will, in helping other people. If you need help with confidence, then you need to keep doing hard things. Honestly, that's just the only way you're going to develop that confidence muscle. Keep doing the hard things, celebrate those accomplishments. Once you get through that. When you do that you are physically releasing endorphins of accomplishments, you are feeling good about those accomplishments. And then you keep doing it. There are physiological changes to what you're doing, when you're saying no, or when you're saying yes to something. And all this influences how you feel and how you think and how you act. So I hope this episode helps you just a little bit. If you think you're feeling burnt out, or you actually know that you are please get professional help. I know this work is not easy, which is why I offer a coaching course, to help you along that but this is completely necessary for your self preservation. A world needs the best version of you not just what's left of you. This is a quote I put in my bathroom and my patients get it. I hope it resonates with you to making time for self care is medically necessary. And wishing you well. I'll see you next week.

Dr. T  21:28  
Thank you so much for being here with me. 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 find my info in the show notes and send me your questions. That might be the topic for future episodes. 

Dr. T  21:47  
And lastly, if you remember nothing else, remember this be the energy you want to attract. See you next time