Growing up, my mother used a rather simple disciplinary technique. When my sister and I misbehaved, she would calmly tell us to go “sit in the bad spot,” a designated place on the kitchen floor. It was, I suppose, the fifties’ version of “time out.” We had to sit there, quietly, until we verbalized what we had done wrong, apologized for it, and then received permission to go play again. The idea was to sit until we “learned our lesson.” 

I began planning my DPC practice in 2013, and in March of 2015, I opened “Hometown Direct Care” with two staff I had previously worked with for over thirty years each. In 2017, I hired a physician directly out of residency and opened a second DPC office. In 2021, another physician just out of residency joined my office. My plan was to slow down, and ultimately turn the practice over to them. It all seemed so perfect. 

Fast forward, I am turning seventy this month, but there has been no slowing down. Both of those two young physicians have left the practice over the past year, each for very different reasons. It has been a disappointing experience. But I have learned some valuable lessons, which I would like to share. Maybe a few of these will benefit someone else. Here are ten such lessons: 

1. Being a physician is still a privilege. I still enjoy the exam room. I love listening, advising, trying to solve problems, and helping prevent problems. Some days I actually think I am getting better at it. Most of us were probably fortunate to get a spot in medical school. Many others did not. I remind myself of that every day. 
2. Patients deserve better. Patients need access, acceptance, a listening ear, and well-informed advice. Their care should be affordable and feel personal. Achieving all that is getting more and more rare in today’s healthcare kerfuffle. One day we will all be patients ourselves and experience being on the other side of the gown. 
3. Physicians deserve better too. Especially primary care physicians. They need the time and freedom to do their job well. They should be able to focus on the patient directly in front of them in the exam room, and little else. Like patients, they should not be handcuffed by an insurance company. They should be well-compensated. In my opinion, no medical student interested in primary care should have to choose another specialty simply for a greater income potential. 
4. DPC offers the best solution for both the physician and the patient. DPC is beautiful in its simplicity. For the physician who has never practiced in a current day traditional practice, or the patient who has never experienced a DPC practice, this can be difficult to grasp. Naysayers are still plentiful, especially those who stand to lose from changing the status quo. I admit that I often worry about the future of DPC. But it is still the best model for physicians and patients. 
5. DPC is better, but it is not easy. DPC solves many problems, but not all of them. For reasons of poor planning, or simply bad luck, some DPC practices simply fail. Physician compensation, especially in the early years, can be frustratingly low. The formula is rather simple: Number of patients, times a monthly fee, minus overhead. No MBA is needed. To take home more, you either have to add more patients, raise your fees, or lower your overhead. Take your pick. (By the way, there is no free lunch. No DPC money tree.) Benefits like insurance and retirement plans can be expensive in a small independent practice. DPC can feel lonely. DPC can feel non-stop and be emotionally draining. Even with a practice of five hundred, and five visits a day (and throw in some calls and emails), the breadth and intensity of the doctor-patient relationships can easily fill the available time and space. Yes, being a physician is a privilege, but it can be hard. Even in DPC. 
6. DPC is not for everyone. Saddled with student loans? Other debts? Saving for children’s college funds? Prefer guarantees and benefits? Just want to show up, be given your schedule, and go home at a predictable time? Prefer not to be “bothered” when “off”? The thought of meeting payroll and covering expenses feels overwhelming? If any of these are true, then DPC may not be for you. Is DPC a viable option for the young physician just starting their career? I am no longer sure. 
7. Bigger is not always better. As I mentioned, I started my DPC practice with two long-term employees. We knew each other well, warts and all. Together we had left a very large system-owned practice. We shared values and a mission. Our goal was to serve our community and provide a different, and hopefully better kind of care. But after a few years, I began to think about my future, and their future. What if I got sick, or died, or simply decided to retire? I concluded that adding physician partners was the solution. Not everyone was in favor. Without going into details, I basically chose to finance my new physician hires myself. I believed with time and growth, it would all work out. It did not. 
8. If you own your DPC practice, then own it. Most of us attracted to a career in primary care tend to be pleasers. We want people around us to be happy. We seek harmony. Yes, hire the best staff you can and take really good care of them. But never forget, it’s your business. Look out for yourself. Try to pay yourself first. Be selfish when you need to be, and don’t feel guilty. Remember, you took the risk. And at the end of the day, you may be the only one left. Let the buck stop with you. 
9. Exiting a DPC practice may be more challenging than starting one. What is your eventual exit plan? Sell the practice? To whom? A young partner already with debt? Private equity? A hospital system, the very devil many of us escaped from? Just give it away? Set a date, and then turn off the laptop, and lock the door? Just keep on working until …? One day almost every DPC physician will face this. Very few precedents have been set. This topic needs further discussion. 
10. Try to enjoy the ride. This lesson may have been my hardest to learn. Had I chosen DPC sooner, I am confident I would have been happier years ago. Life is short. Time truly flies. I am a planner, a prodigious one, but obviously not always a perfect one. Stuff happens. I am trying harder to live in the moment and embrace the unexpected. I am trying to know when to let it go, and when to move on. Next play, as they say. 

OK. I have been in “the bad spot” too long. I have learned some lessons. 

May I go? Time to see a patient. Return an email or two. And then, if I have time, maybe catch a fish, or try to beat my grandson in one-v-one.

Thanks, Mom, for making me sit, think, and learn.