Tea Nguyen, DPM (00:55.84)

Seven reasons I've put together for why doctors should not go into direct care. Now you should know I'm a big advocate for independently owned practices. I think we've seen that consolidation tends to lean towards decreased autonomy at the cost of quality care and relationship erosion between the patient and the doctor. Not always, but too often. I'm also a realist and I can see that this model is not for everyone.

At the moment, it's less than 1% of doctors practicing direct care who own a private practice. Now I like to compare direct care to the farmer's market. The farmer's market is very niche. It's not exactly mainstream like a grocery store, right? And there's this one that I go to every Sunday where I pick up a bouquet of flowers for myself and I meander, I browse around checking out what's in season in regards to the produce.

There's entertainment, there are pastries, and I like to pick up a dozen eggs, which right now costs $13. Now that's a drastic change from store-bought eggs, which can be bought for $4 or so. And I got to thinking, why do I enjoy spending that extra money for the exact number of eggs? They're both edible. They're safe. One is easier to access because I can get it Monday through Sunday, whereas

The farmer's market is only there like four- three hours on a Sunday. What is so different with the farmer's market experience? Here were a few things that came to mind. The first thing for me is because I can, I can afford $13 for a carton of eggs. And actually the people who provide the eggs, they are locally owned farmers who are my friends, and I just think their eggs are excellent. So maybe I have some bias with that. So

Because I can and I want to support my friends. I also think they taste better. If you've ever had organically grown chicken eggs, they are totally worth it. At first I didn't think that was a big thing. I always grew up with market eggs. We bought eggs that were cheap. That was good enough for us. I grew up on a low income, first wave of immigrant parents came here. I was the first generation born here. I think that's how you say it. Yes, so we didn't have a whole lot of resources.

Tea Nguyen, DPM (03:25.624)

You just ate whatever we could afford. I remember growing up on kicks cereal or rice and soy sauce. We didn't have a whole lot growing up. But I know what it's like to be mindful of how you spend. And so we kind of grew up this way, bought the cheapest stuff, right? And then life goes on. I made adult money and now I have choices. And now I've discovered the choice of buying farm eggs. And they're very, very good.

So lucky if you have your own eggs that you get to harvest, or I don't know what the term is, that you can have on your own property. I get them at the farmer's market. So short story, just because I can. And I enjoy that freedom, that luxury, really. They taste better, I mentioned. The experience of going to the farmers market is really cool. I go there and I meet the local farmers and everyone's friendly and nice. There's lively music.

There's a lot of people that I often run into. It's a small town. And it's just good vibes there. I love to support local businesses. And actually, I recently got my hair done also by a friend. And I asked her how much she was gonna charge me. And she said, I don't know. I feel really weird charging friends. And I said, let me tell you something. I love to spend money. Let me tell you why. I love to give my friends who have an awesome skill for something I can't do for myself.

I love to exchange their service for money that I have. It makes me feel like I can afford it. And I love to support local businesses. And she said to me, That's a different perspective. And I said, Yeah, so let me spend my money. Let me feel good about spending money. So that's my tangent story about the farmer's market and my hair and all the things. I love to spend money. And there are people out there who love to spend money because they can. And it just makes me happy and I know it makes other people happy to spend on things that they already want. And I know that the money is going to go towards something meaningful, like the direct to farmers, like directly to the farmers and to their employees and to maintain this farmers market. So just some reasons that came up. I wonder if you have your own reasons as to why you're choosing something more expensive or another. And that's very much what happens in direct care. People who pay out of pocket

Tea Nguyen, DPM (05:49.986)

For direct care practices, the perception is that they are paying more because they're used to having insurance cover things, right? But that's not always true because sometimes they get hit on the back end with a deductible or they're paying into their insurance premiums, or there is a surprise bill that nobody knew the price of, so nobody can prepare them for. And that's not to say that you should be encouraging your patients to not have insurance. It's really about price transparency or the lack of it.

And so in direct care, because we have price transparency, we can have more honest conversations about what things really cost. And patients can take that information and shop around and decide if it's worth it to them to shop with you. I believe my patients feel the exact same way when they come to my office and pay for my services, the way I feel about going to the farmer's market or going to my friend to get my hair done.

And keeping them in business because I've gotten a service that I'm happy with. And I know them personally. So I wouldn't bag them online with a negative Google review, right? There is respect, there is understanding, and the relationship is just a lot tighter. I've had patients who have been with me for years and they say things like, please don't leave. All of my doctors are leaving. I don't want to find another podiatrist.

Or the reason I'm doing business with you is because I know you and I know you'll take care of me. And many of them are also small business owners who are supporting one another. We are all small locally owned businesses and we find value with that. So it's this relationship that is built over time that makes it even more valuable. For both parties, it's like I come into work and I see the same people I've been seeing for over seven years and we're just catching up on the latest gossip. It's like seeing an old friend over and over again. And I love that so much. That is the reason why I chose podiatry back in the day when I was shadowing and I was visiting a podiatrist office and I just saw the way he was interacting with his patients. It was like even though I spent just a few hours with him, it felt like they knew each other for so long.

Tea Nguyen, DPM (08:10.766)

There was light banter and everybody was happy. And I wanted that for myself, which is why I chose to go into podiatry. Patients just knew and loved their doctors. And that's what I wanted. So we skipped ahead into our training and then the work suddenly felt more automated, more robotic, more numbers driven, where we have to see a lot of patients.

To feel productive, to make more revenue, whether it's for the business or the business owners. And then we rushed through the process of taking care of people. Only by the end of the day, I couldn't remember all of the faces that came through. And I missed a lot of the small details about the patient. It started to feel very disconnected. And then I started to resent that version of medicine. And then I got worn out.

These 15-minute slots ended up being more like six-minute visits, but the follow-up, the ordering of things, the coordination of care, all of that requires a lot of time. My deepest joy is helping at-risk patients prevent leg amputations. And a lot of that kind of work requires developing trust with the patient, and that requires time, which it seems that we have less and less of it if we continue to work in corporate medicine or we take insurance.

And I found it was very difficult to earn the trust of patients when interactions were quick and they were left confused, or they didn't have enough time to process or ask questions, or simply just having the space to digest their options. Medicine is so much more than a diagnosis and a prescription. We think it's supposed to be a textbook, right? That they come in presenting with.

All of the exact symptoms the book shows us, and we have multiple choice of answers and prescriptions and treatment options. But humans are messier than that. The human component is really hard to incorporate in corporate medicine. So here's the truth that I've come to realize: not every doctor should go into direct care. Direct care fills a gap.

Tea Nguyen, DPM (10:26.016)

If everyone went into direct care, I really don't know what the system would look like. In my idealized world, I think more doctors would stay in clinical practice. They would be happier. But it's just not practical. There are doctors who are still needed in hospital settings, like pathologists, radiologists, ER doctors, hospitalists, trauma surgeons, and so on, high utilizers. That's where it makes sense to stay in the hospital setting.

So I'm gonna share with you the seven specific reasons to not go into direct care and that was the very first one. If you're in a specialty that doesn't translate to cash pay.

Then don't do cash pay. It doesn't make sense. Now there are some doctors who do both, where maybe they have a hospitalist or locum job. And because they have a locum job, they are contracted with Medicare. But they are also building a direct care practice off to the side in something totally different. Maybe it's in regenerative medicine or aesthetics or some other type of service that's either not covered by insurance or it's very specific and separate from the Medicare contract. There are some insurances that don't even allow you to do membership outside of what you bill insurance. It's very confusing. There's a whole talk about this in one of the episodes where I talked with an attorney about

The nuance that is needed to understand how you can do kind of this hybrid setup. So I won't go too deep into that here, but just realizing if your specialty does not translate into a cash pay model, then that's where you wouldn't pursue it. Number two, doctors who are running away from the wrong thing. Here's what I mean: if the real problem of your current situation is that you have a bad employer.

Tea Nguyen, DPM (12:22.444)

Maybe a new job would fix that. Maybe not. We don't know, right? You have to diagnose what the actual problem is. If autonomy is something that you value deeply, and you feel like you don't have that in your current situation, or you can foresee that no matter what job you take, that that will not be preserved for you. Nobody else is going to look out for you as much as you do. So you have to keep that in mind. Then you would have to consider that you're gonna trade in a boss for other responsibilities, which include things like marketing yourself, payroll, managing your phone systems and other operations. You become the operator. Now this excites some people while it sounds very exhausting to others. So if it doesn't excite you, then it doesn't really seem to be worth doing. It doesn't feel like it's going to be worth the risk because there's gonna be a lot of work involved in building this thing.

Number three, the doctor who won't sell. Not because they can't, but they truly don't want to learn it, or it feels like it's beneath them, like they shouldn't be having money conversations with patients. The thing is, doctors sell all the time. We are selling patients prescriptions with side effects, surgery with significant risk and downtime. We are actively selling. Selling is educating, it's telling them here are your options, and I'm guiding you towards the one that's gonna work best for you. And we talk about the risks and benefits. So we are selling all the time. What's different in direct care is now there's money attached and it goes directly to you. And people feel weird about that. And I get that.

But if you're the kind of doctor who feels like you never want to sell, or you're just not willing to learn how to do this correctly ethically, then it doesn't make sense to create a business where selling is required. Number four, there's no financial runway or plan. If you're the kind of doctor who hasn't planned out what this looks like, you may be putting yourself at financial risk.

Tea Nguyen, DPM (14:37.966)

For me, I took out a loan to start my practice in 2018 and I did take all of the insurances and I couldn't pay my credit card bills in the first year. It was awful, it was embarrassing. I feel like I'm over it, so now I can share that. So I took out a business loan and used my personal savings. So everything was on me.

And a lot of doctors may or may not have that. You may have different types of resources. You may not have any resources. So you have to decide what that looks like for you. Some people marry rich, some people have stocks that they can withdraw from, they have additional savings, they have another job, and so on. So look at the realities that you have and decide where you're going to allocate your resources. So whatever your situation is, having a financial plan, especially in the startup phase, can make or break your progress. If you run out of resources, then there's nothing else running the engine, so to speak. This is not the kind of business that really lends itself to private investors. At least that's not a common pathway, to my understanding. Maybe crowdfunding can become a normalized thing down the road, but as of today, I haven't heard this being true for a lot of direct care doctors. We have to fund it ourselves.

And I mean there were corporations that had set up these concierge type models, but some of them didn't last very long for obvious reasons. They were still taking insurance and they realized insurance wasn't paying them very well. And also the model wasn't driven by physicians, it was driven by people who wanted to make a profit, but at what cost? You know, the patient care, of course. So realize that there is a reward.

If you build this thing on your own, it just takes time and it takes resources. And I think that's the whole point of life, personally, that you're here to create, not just have things handed to you. But perhaps that's a conversation for another time, maybe over some adult beverages, so that we can get real deep into the meaning of life beyond your clinic walls. So moving on to number five. If your household

Tea Nguyen, DPM (16:49.962)

Or your team is not on board with direct care, there's going to be a lot of resistance. I had a doctor from a group practice who attended one of my conferences, my conference lectures, and he was very enthusiastic about direct care. We all hated the same thing, right? We all have a common enemy, which is insurance, in the way that they don't let us practice medicine, right? There's a lot of restrictions. So he was very hopeful about the possibility of opting out.

But if you're somebody who is part of a system, part of a private practice group, part of a behemoth of a system, what would happen if you opt out without a real plan? Financial demise. Because here's what really happens when you opt out. You will experience a decrease in patient volume, which is going to affect your revenue. It will create instability if you don't have a legitimate plan.

And then that will put everyone at risk. The people you employed, the structure of your business, of that business you're a part of. And so what I mean by the household or the team, it's where you're at. If you're in a private practice, that's the team. If we're talking about the household, we're talking about your partners, your family, etc. Having a partner that makes hard times feel lighter is essential. Now I'm not here to give any relationship advice as you know. I am going through a divorce. So I'm not in the position to tell you what to do with your relationships, but I can tell you from personal experience how much this matters. Because if you both are not growing in the same path in the same direction and there is resistance, there's stunted potential, that might even lead to divorce For better or for worse. Again, I'm happy to discuss these things over adult beverages because there is nuance, there are considerations, there are conversations, maybe even therapists need to be part of your plan. But it's very important to understand how important your support network is because building this type of practice takes a lot of effort. It requires a lot of your time, a lot of your resources, and you certainly don't want to build this at the expense of.

Tea Nguyen, DPM (19:12.61)

A meaningful relationship. You don't want to put that at risk without laying it all out and have a mutual understanding of what the reality is going to be in the next couple of years. All right, number six the doctors who should not be going into direct care are those who find that their identity is being part of an institution. They like the title, they like the predictability of a paycheck, they like the structure. And this is a very legitimate thing to want these things. And if you do, then it doesn't make sense to walk away from that comfort. Now, some doctors are able to maintain their professorship part-time.

And build a direct care practice simultaneously. While some choose to walk away. Like for me, I was a department chair. I was part of a growing wound care center. I had amazing colleagues. All I needed to do was just show up. I had a team of nurses and staff members to support my services, but at the end of the day, the structure just didn't sit right with me.

And I have to say I do miss that deeply. That structure of just showing up, being the doctor, and everything else is taken care of. But my vision was so much bigger. So I had to make room for that, which meant I had to let go of that identity. And it was so very hard. But I can say that I don't regret it. So this is my reality. And

I know if things change in the future, that that door isn't completely closed and sealed shut, I can always change my mind again tomorrow, right? We'll just have to wait and see. Number seven, the last point here, is that the doctor who should not consider direct care is the one who doesn't have the capacity to make decisions in the absence of certainty.

Tea Nguyen, DPM (21:10.378)

In general, business ownership might not be for you if you cannot make decisions without knowing there is certainty at the end of the road. Some people thrive in this kind of environment while others don't find value in that or it's too risky on their nervous system. They're not okay with this. This is not fun at all for them. And it's good to know yourself well enough so that you make a choice that works for you.

But if you're a dreamer, you are a visionary, you value your independence, you are willing to move forward with very little information and nearly no certainty, but you have some faith, then you should go for it. Because there is a pathway. Many of us have done this, you're not going to be the first person to do it. There's a smart way to do this.

Most of all, I think the most valuable thing is that you start to develop a very thick skin once you go into entrepreneurship. This is something you develop in the process. You don't just intellectualize how to have a thick skin, you actually gotta do the work and feel the pain and develop some resilience with that. If you're that kind of person, you love personal development, then entrepreneurship is totally for you. You should definitely consider direct care if this excites you.

So there are many more reasons to not go into direct care, but there are so many reasons to choose it. People talk about risk taking, but the thing is, there is risk in any decision you make. And indecision is also a decision to stay still, to stay the same, to be exactly where you are a year from now.

The idea of security is an illusion. Many doctors have reached out after they were guaranteed a job only to realize they either hated it or they were suddenly let go without proper notice. And a few of those doctors had a tickle for something more. They've been reading my LinkedIn stuff, listening to the podcasts, listening to the lectures I attend, things like that. And they don't know if it's for them.

Tea Nguyen, DPM (23:20.674)

But I'm here to help you entertain it as a possibility. Because direct care is not new, the path is already there. It's growing exponentially amongst many specialties. So if you're the kind of doctor who is feeling a pull towards direct care, but you are not exactly sure of where to start, I want to invite you to a phone call. And I made this very simple.

There's a link down in the show notes where it says contact me and it takes you to my webpage. You put in your information and I get the email and I will reach out as to how we can schedule a call. And that's it.

There's no commitment to the call. It's just you and I talking, figuring stuff out, sorting through all of the questions, concerns you have floating around in your head, and we're gonna make it a tangible plan as to what you need to do next. If that sounds good to you, use the contact button down below.