Tea Nguyen, DPM (00:53.902)

Are you afraid direct care means that your phone will never stop ringing? I'm walking you through a real day in my insurance-free Podiatry practice, including what happens when a patient calls me with something urgent. We'll talk about the fear of being available around the clock and how you get to decide exactly what your practice looks like. This is episode 247, which turns out to be a happy accident on Do You Actually Need Be on Call 24/7? So let's get into it.

Doctors here, I don't take insurance and think that means I'm on the clock twenty-four seven with some stuck up rich folks. And that could not be further from the truth. So let's see what is really going on when doctors leave insurance for a direct care practice and how they make it work for them. Physicians typically we don't clock out. We lose nights worrying about our patients. The work swallows us whole. It's all consuming.

And back when I was doing hospital work in the wound care center or performing surgeries, those patients were often in bad shape. They were in critical conditions, at risk of losing a leg, at risk of having their infection get worse if things were not treated promptly. So we were trained to understand that access is everything to the patient. It could be life-saving. And having that pager, especially during residency, I remember clipping on two pagers.

And they were heavy. They were like these brick batteries. And when it would go off, there was a timeline. There was a period of time we had to respond to that. And year after year, we developed this level of urgency and anxiety around responding quickly, making sure we respond appropriately, not missing a diagnosis, making sure treatment plans were timely and so on, so that we don't harm the patient. But that's not actually what we're building here in our private practice.

You see, the structure of the hospital setting is totally different from private practice. Private practice, there is more elective care, more preventive care. There is some grace period in a private practice when it comes to how soon you can respond to the patient. So if you're wanting to build something sustainable, make sure you understand that access to you should also be sustainable. So what's urgent in my podiatry practice? For me,

Tea Nguyen, DPM (03:20.096)

It's usually in the way of an infection or sometimes post-op pain. That's about it. I don't really get traumatic injuries like somebody falling off a ladder and breaking a calcaneus or the heel bone. That usually goes to the hospital. Sometimes I'll get a sprained ankle and somebody needs to know if they broke an ankle or something. So I can manage that, but it's technically elective. And that's the thing, is knowing that I am a specialist that does very specific things.

I'm not selecting for emergency or urgent types of care. It could be urgent with my patients who maybe they went to a nail salon and got an infection and that needs to be managed. But I am also very aware that I'm not really the first point of contact for many things. A lot of my patients have insurance and they also have a primary care doctor. In my community, we also have access to urgent care centers and

The ER for true emergencies. So it's not like my intention is punting off things that I could manage. It's really realizing that we have resources that allow me the liberty to choose what's gonna work for me as an individual solo practitioner. I don't have a team of people in my practice. It's really just me and my assistant. So the last thing I want for my patients is for them to rely on me 24/7. 

That is not healthy for anybody. That is not healthy for any relationship. So I'm not really going to condone it. So what I'll do for you today is take you into my practice, what a typical day looks like when something urgent comes up. And it really starts with preparing your patients for what you can and cannot offer. I think luckily for me as a podiatrist, most people don't seek my care for emergent situations. But sometimes I perform a procedure or a patient had an accident and they just know that we are accessible. 

So what does my typical day look like? In the morning after getting up and getting dressed, getting my daughter ready, feeding her, get myself caffeine of choice of the day. It could be coffee, tea, with or without protein, some mixture of that, and then I get going. You may know that I'm going through a divorce right now, so we have split custody. So when I have her, I get to pack her lunch and write her

Tea Nguyen, DPM (05:41.174)

a little riddle on a post-it note for her to enjoy in her day. And as you know, the separation, divorce things bring in a different layer of stress, but listen, this is real life. We're handling it. Drop her off at school. And then I get to my office. I get to the office, I check the schedule, I make sure my inventory is stocked up. I've got my supplies for the procedures of the day. And my last medical assistant was accepted into nursing school, so I actually haven't had anyone in that role. So right now I'm in the practice by myself. I am personally more at peace when it's just me. I feel like it's just meditative. I'm in my zone. I know where everything is. There isn't a lot of double checking other people's work or training that needs to happen. So right now my setup works for me. Back in the day when I was taking insurance that looked totally different. I had three exam rooms running simultaneously so that we can finish a procedure on one side move on to the next without having to wait for a fast turnover even though we still had to have a fast turnover or another room for dispensing orthotics or doing laser or things like that. Right now I have one exam room. Everything happens there. I'm never overbooked and we finish the transaction within the exam room. So at the end of the service or the treatment that they're there for, I collect the payment, I put the card on file, and I close out their account.

I also schedule their next appointment. And all of that takes maybe less than five minutes. Instead of having them go to a different area in the office and have somebody else close out their account like an assistant, how I had traditionally had my practice in the past. Now everything is just so lean to do everything in the exam room from procedures, surgeries, consultation, payments, appointment setting, and so on. So that's what a typical day looks like. Now let's say there's a new patient who needs to be seen. They were referred by somebody in the community who knows I exist and I often am able to see them the same day. I don't like to ignore infections. So I'll find a time to fit them in. In my schedule I have breathing blocks, meaning in the morning I have a block where there are no patients. And then I also have a lunch period which I try to protect but sometimes when things need to be done, patients need to be seen, that time is there for them. And then I've got a block in the afternoon. So my typical

Tea Nguyen, DPM (08:07.544)

Full days are nine to four. And Fridays I'm doing a nine to twelve. So I have a rhythm in my life and in my practice. I've got these breathing blocks so that I can fit in those urgent cases, whether it be a new patient or established patient. Back in the day when I was taking insurance, my schedule was packed. Every 15-minute blocks were filled or double booked and sometimes triple booked. And you know that when you have that kind of schedule, an add-on.

Or an additional question can shift the entire day. And that created more anxiety for me, more stress. And then I never really had an end point, it felt like. And even when the clinic day was over, there was twice as much work to do because now we've got to complete the billing stuff and the charting and the follow-ups and so on. And that has proven to me over time that that is not sustainable for me. It's not something I enjoy. But now that I've taken the middleman out.

I know that I can do better because I'm charging better too. My time is worth more. And that's the whole point is creating something that is sustainable and viable. So what actually happens when an urgent call comes in? My virtual assistant lives in the Philippines, so she answers our phone calls on her laptop. She's able to navigate questions, she recognizes our established patients, and she messages me on Google Chat As to if we can fit somebody in that day. Most of the time the answer is yes. My assistant tells the person who's calling that we do not bill insurance, but we're happy to see you in the same day. And they say yes, let's book it. My assistant sends them digital forms that covers exactly what we talked about, that we don't bill insurance. This is the price of the visit. She then puts a credit card on file and then the paperwork is done.

Now, established patients because I know their medical history, they don't have to rehash everything. They can be seen just as fast. And a lot of these patients that I have, I know what their patterns are like. I know when to anticipate an infection, what antibiotic that they prefer, and I understand what worries them, which is so helpful in triaging my patients. If my patients can't describe what's going on, they can send me a photo, and most of my patients luckily have an iPhone where they can just take a photo.

Tea Nguyen, DPM (10:29.324)

Upload it or send it to me and then I review it. If it sounds like my voice is getting raspy, it is. The air is dry. I've been talking a lot. That's all that that is. So anyway, the patients are able to be seen the same day for those urgent matters. I actually don't think any patient has ever tried to reach me after hours. I've definitely never had patients try to call me around the clock. It just doesn't happen. Patients know to contact me, it's by email, which also means urgent things don't go through by email because

I'll get to them when I get to them, within 24 hours, preferably. So I know I can manage that. Now I know some specialties attract some patients who need more touch points. Some call them overutilizers. Sometimes it's just the nature of the problem. So for me, diabetic foot ulcers are ones that need to be seen sooner, especially if something has shifted in their health, developed a fever, they're just not overall feeling well. Because I know those things that sound benign can turn urgent fast, they are also educated on what to do when something happens and they can't reach me. So it's all about preparing the patient for what to expect in my practice. Knowing the type of person you're attracting is very important. And this is the part where you get to design your boundaries. So tell patients how it works out loud and on paper. The things that you can and cannot offer. So I'll tell patients something like.

You can email me and I will try to respond right away. But if you don't hear from me within 24 hours, contact your primary care doctor, urgent care, or ER. Please don't wait. So we make this very simple. And I think a lot of us struggle here because our boundaries have always been violated, one way or another. So you want to be very specific about how you want to be reached. For me, it's the patient portal or just call the office. I do respond within 24 hours for urgent situations and otherwise they have all these other resources in their community. That's not me punting work. This is because I know my limits. My work hours are limited. And I have patients where if I did a procedure, I keep them in mind and I chicken on them so that we catch stuff before they get overblown. I would say a hundred percent of my patients respect my time. I've never felt taken advantage of for allowing this access.

Tea Nguyen, DPM (12:49.142)

If for some reason a patient goes back and forth with me by text messaging, email, or a patient portal, and it's just really long, I have my assistant call to clarify what it is that they need, and otherwise it becomes an appointment because I don't want to miss anything that's being conveyed in words that needs to be seen in the clinic or a virtual visit. And nothing kills my joy faster than doing this back and forth thing. I just don't love it.

So if you're somebody who is employed, you are probably used to somebody else designing your day. You clock in at a certain time, you clock out at another time, or if you take insurance, your practice is geared towards a volume-based type of practice where it leaves no room for add-ons or it shifts your entire day if you try to accommodate them. And that's what's different about direct care. You want to be able to be clear on what you're going to bring in.

So before you hand out your cell phone numbers, and yes, a lot of direct care practices do offer patients our cell phone number or a way to contact us directly. Before you do that, ask yourself these three questions. Number one, how reachable do you actually want to be? And what? For me, I don't like anything after 5 p.m. I can look at a text message or an email after 5 p.m., but patients are fully aware that I've got a kid, I've got a life.

And they respect that and I respect them. I don't even like having meetings in the evening because I try to protect my time. I am very stern about when I am and am not available, with rare exceptions, obviously. The second question to ask yourself is how many patients can I serve at this level and still have the life I want? So if it's six patients a day, that is completely reasonable. Declare it.

But if you're still used to seeing 20, 30, 50 patients a day, this is gonna shift for you a little bit. The downtime might even feel uncomfortable for you. But look, if you're charging appropriately and you want that work-life balance, this is how you do it. You create those boundaries so that you are sustainable. And then number three, what does emergency care look like in my specialty? As a solo practice owner, I understand a lot of this weighs on you. So perhaps future plan.

Tea Nguyen, DPM (15:05.538)

Think about what MAs can do for you in f as far as triaging a phone call or having a nurse or another part-time doctor or even a partner in your practice. And select for care that doesn't need urgent attention if that's not something you enjoy. So for me, I stopped doing certain surgeries because the aftercare was too resource heavy. So I don't perform amputations anymore. I send that off to my local friends who have their resources and don't mind.

Doing those procedures. Now I want you to realize something if you haven't realized this for yourself, and it's this: you don't need to earn your time off. It is a prerequisite for optimal functioning. If you look at a professional athlete, time off or an off-season is just as critical as the training period. Your body needs it, your mind needs it. So have protected time off and defend it as much as you can.

But also prepare your patients for what their options might be like should they need urgent attention. I run such a lean practice that I find it impossible to not succeed in this model. But in order to do so, to have it be sustainable and profitable, you have to declare your boundaries because no one else can do that for you. I'll leave you with this one quote that sits in my bathroom, in my office, in the clinic, and it says, Self-care is giving the world the best of you.

Instead of what's left of you, which is a famous quote by Katie Reed. Thank you so much for being here. I will catch you next week. Take care.