Five seasons ago, I planted my first “straw bale garden” after reading about its advantages: simple, easy, weedless, versatile, and perfect for the aging gardener who might benefit from a raised bed. The concept is easy. You obtain bales of straw. Not hay. (There is a difference.) Prep them with water and fertilizer for two weeks. Plant most anything except large melons. Water when needed. Fertilize regularly. Be patient. It works. 

This past weekend I began to “take down” my latest garden, pulling up and cutting out some of the already dead plants. There are a few more tomatoes to ripen and pick. And some more squash, zucchini, and cucumbers to grow a little bigger and harvest. But this summer’s garden is near the end. 

As I picked some of my end-of-season cucumbers, a crazy idea came to me. Cucumbers are a lot like DPC practices. Yes, that is what I said. Most people enjoy fresh cucumbers and appreciate their health benefits, of which there are many. However, an occasional person experiences GI upset (which, by the way, is due to the chemical cucurbitacin.) Most people who experience DPC are happy, including doctors, staff, and patients. But DPC is not for everyone. Income can be greater in the traditional employed model. Limited benefits can be unappealing to prospective staff. And many patients either just do not get it, or simply feel they “must” use their health insurance whenever possible, even for primary care. 

My apologies for getting in the weeds (and the pun), but please allow let me to explain further: 

1. Cucumbers need the right soil. It should be loose and well-draining, with the right pH. Cucumbers can be grown in virtually every state in the country. We have also seen that DPC can thrive virtually anywhere. But location does matter, especially for ideal growth. Although much of the work of the DPC practice can be done remotely, the physical office conveys the personality and values of the physician and the staff. Is it on Main Street? Is parking convenient? Can patients walk to it? Is it in a fast growing part of town? Is it visible to potential customers? Does it look like a traditional office, or does it send a refreshing new and different message? There is also a basic financial consideration. Do I buy or do I  rent? There are advantages and disadvantages to both. Where and how you put down your roots matters.
2. Cucumbers need full sunlight, at least 6-8 hours and better if the early morning. Photosynthesis aside, the sun is also needed to dry the leaves to reduce unwanted insects or other predators. Likewise, a DPC practice needs a light shone upon it in order to grow. Where to advertise may be a matter of location, targeted patients, and budget. Social media? Print? Radio? Community involvement? Word of mouth? Different DPC practices have found what sunlight works for them and their community. 
3. Cucumbers need periodic fertilizer, more in the beginning to prep the bales before planting, and then about once monthly, making sure it has proper amount, usually a 5-10-10 mixture of nitrogen, phosphorus, and potassium. Too much fertilizer, though, can be harmful. Before I opened my DPC practice back in 2015, I sought ideas and guidance from multiple sources: already established DPC doctors (like Brian Forest, Julie Gunther, and Josh Umbehr), books (like Doug Farrago’s), and conferences (such as the DPC Summit, and Nuts and Bolts). However, I do recall feeling overwhelmed with ideas and advice at some point, and eventually simply had to choose what made most sense for me. Even so, after getting established, I found myself still needing a periodic dose of motivation, camaraderie, and new ideas. With my cell phone, social media, and live meetings, coupled with the incredible collegiality of the DPC community, I learned I could get my “DPC fix” whenever needed. Friends and fertilizer for life. How cool is that! 
4. Cucumbers need just enough water, about an inch a week, but this depends on the weather and geography. Too little results in poor growth; too much can cause rotting and disease. It’s like Goldilocks and the soup: not too hot, not too cold, but just right. As I think about DPC, and what I have done well, and what I have done poorly, generally I realize that DPC pioneers who went before me figured out so many things, sometimes the hard way. When I adhered to their vetted ideas, things generally went better. How many staff? What to charge? What to offer? Listen to the pros, and you are more likely to get it “just right.” 
5. Cucumbers need to be pruned. Under the right conditions, some varieties (climbers as opposed to bush types) can grow in too many directions and take over a garden area or even the lawn. Setting out a trellis to enable them to grow up, and not out, can help. Occasionally you have to cut back branching offshoots so the sun and the bees can have access to the flowers hiding underneath. But discretion is important. The open ends are inviting to small invaders, so one must be careful. A DPC practice has to prune occasionally too. There are patients who “need” to leave for the sake of the doctor and the staff. Overhead needs to be re-examined regularly, making sure everything is truly needed and essential to great patient care. And rarely, but also critical to remember, even a staff person may need to go, if they are not the right fit, for whatever reason. 
6. Cucumbers can get too big. A cucumber gardener needs to check their plants almost daily. A very small “fruit” can emerge one morning, and before you know it, has grown to a “pickable” size in a matter of days. And if it is hidden under the canopy of leaves, it can grow to incredibly large and inedible proportions before being seen. While a fledging DPC practice needs to grow, and panels need to get to the 500-600 patient level to create financial stability for most practices, too big, too quickly can lead to problems. Poorer service. Too much like the traditional practice world we left. Overwhelming for the doctor and the staff. Being aware is key. And most important – as you grow, take a moment to slow down, enjoy your success, take a little profit, take a needed vacation. It’s OK. Growth can resume. 
7. Cucumbers grow tenaciously. The plants do not know where they are headed (at least I do not think they do.). They simply grow and spread, and they grow tendrils which can wrap around a trellis, another plant, or any nearby object in order to spread even further. Likewise, successful DPC doctors tend to be tenacious. They start small. They control overhead. They look for discounted supplies and equipment bargains. They talk to employers and they seek new business. And they refuse to let go. They do not want to go back to the abusive world of employed practice. Their tendrils are effective; their resolve ferocious. 
8. Cucumbers like and dislike certain neighbors. It is advisable to not plant cucumbers next to potatoes. They do not like each other. But next to certain crops, like radishes or tomatoes, cucumbers do better. Certain pests, like aphids and beetles, can be problematic. So can fungi and viruses. Bees, of course, are necessary visitors for pollinating the flowers. Likewise, DPC practices need to be careful about their neighbors. The predators are well known (yes, I am likening some administrators to slugs and worms!). We also need pollinators – certain doctors, staff, and even patients – who are able to infuse ideas and energy when needed to even the most mature of DPC practices. In my experience, certain other health professionals can be a good fit for DPC – therapists, chiropractors, nutritionists, aestheticians, other cash-based subspecialists, to name a few. They “get it” that patients are looking for a different experience, and that paying “cash” very often makes sense. Co-habitating with a “potato” who lives and breathes “insurance” can send mixed messages to patients, and detracts from the value of DPC. Said a different way, hybrids are risky bets. 
9. Cucumbers come in a number of varieties. There are many – green, white, yellow, spined, spineless, long, round. An entire book could be written. As we all know DPC doctors and practices are very diverse. If you have seen one DPC practice, you have seen one DPC practice! I hope we will continue to encourage and embrace this diversity. This gives us more traction. More options for medical students and residents. Greater opportunity to avoid labels and generalizations. Rural, suburban, inner city. Ethnicities. Genders. Sexual identities. Employers. No employers. Insured. Uninsured. Areas of special expertise. I could go on and on. 
10. Cucumbers come to a seasonal end. I always hate when I have to begin to cut out my dying plants. I truly feel a sadness inside. And I cannot wait to plant my straw bales next spring. Personally, my DPC run is ending. By 2023, as I turn 69, I will have turned over my practice to my 2 young and amazingly physician partners, Drs Josh Carpenter and Brianna Buchanan. This is not easy. I have plans and exciting things to do. But I do not have another DPC spring to look forward to, except to watch and admire my partners, and all friends still in practice. Fortunately, I have planned well financially, and I have enough hobbies and interests (like straw bale gardening!) to keep me engaged and excited for years to come. My fear is that many in the DPC world, still climbing that career trellis, building that practice, and trying to “get there”, have not laid out their “exit strategy.” As our movement moves forward, and those now in their 30s and 40s reach their 60s and 70s, knowing how best to end a garden, and not just how to plant it and grow it, will be a need and a priority. 

DPC. As cool as a cucumber. Who knew?