Many of us in the DPCA community are avid sports fans. Ryan Neuhofel and the Kansas Jayhawks. Jeff Davenport and Oklahoma State Cowboys, Amy Walsh and the Michigan Wolverines. Shane Purcell and the Georgia Bulldogs. My team happens to be Duke, and my favorite sport is college basketball.

This phrase – “You Got To Hit Your Free Throws!”- is frequently uttered, and too often screamed, in my den during basketball season. It has been a tradition for many many years, since my children were old enough to wonder why daddy was getting so upset on Saturday afternoon with that thing we call a television. My family and most of my basketball friends know that I strongly believe that many games are won and lost on the free throw line. Coaching, rebounding, defense, and three pointers all matter. But sometimes, these are all for naught if your team is not dependable at the line.

This phrase has even extended to other aspects and events in my life and my family’s, like projects, financial planning, events, and even child raising. Make sure the basics are covered first and done well, and not overlooked. All the other more complex and fancier decisions are certainly important. But do the basics well. Make sure there are enough seats at the wedding. Make sure the groom shows up, sober. Don’t forget the rings. 

What does this have to do with DPC? I am as excited as the next person to see so many physicians turning to DPC, starting practices and joining practices. It is fascinating to follow all the discussions and hear everyone’s viewpoints on such matters as what to charge, what is reasonable rent, how much space is needed, which electronic health record to use, is there a best communication system, contract with employers or not, where to buy supplies, and how big is too big. 

These are certainly the kinds of decisions that must be answered to start and grow a DPC practice successfully. I offer this essay today as a reminder that there are even more basic tenets to remember, decisions and habits which I think go along way to make for a happy doctor and happy patient. Fundamentals that make such a huge difference, in my opinion, but too often get overlooked in our excitement to make the jump and then grow. 

Here are the basics I think critical to a successful DPC practice. In fact, I think they apply to being a better physician, no matter the model or the specialty. 

1. Hire and pay the best possible staff. If you are starting out solo, you may only need one staff person, perhaps a “Jack or Jill Of All Trades” who can manage the administrative and clinical duties, who can do venipunctures, who can perform an EKG, who can manage the schedule. In our efforts to control overhead and try to get financially solvent as soon as possible, it can be very tempting to hire “cheap” and assume that we the physician matters most, that we are the heart and soul of the practice. In some ways, we are. But whether it’s your initial staff person, or someone you are adding later, hire the best person you can, know them well, pay them as well as you can and even more than you think you can afford. Most of the time, this will be one of your best investments. They truly are the face and voice of the practice. They are our best marketers. People will come and go based on their smile, the interest they show, the caring they demonstrate, and the professionalism they exude. They make us look good, even on our bad days. 

2. Be accessible. Most of us left the traditional fee-for-service world because of the demand for “productivity,” for having schedules of 25 to 30 patients and being made to feel less of a doctor if we cannot do that efficiently and happily. We all love the lower volume achievable in DPC. Seeing four patients in one day and having time to take care of each one is such a gift, and one which is hard to describe to a physician who has not joined the DPC ranks. But I am concerned there is a trend in DPC – COVID concerns aside – a temptation that can be risky, and that is the goal of having “zero days.” Yes, seeing no patients on a given work day, or the fewer the better. We should all admit it. We like it when it happens. We sometimes celebrate a “no show” or cancellation. But one of the main reasons DPC has been successful, is accessibility, the ability to see the doctor (or even the office staff!) when something is needed. I get it that even on those seemingly less busy days, there are many touches by email, text, and phone. That is access too. But I caution us to not forget that very often patients just need to be seen. In person. Listened to. And touched. (Keep reading). If we are hard to see, or if we subtly or overtly discourage the in-office visit, even those visits that can be handled by email or phone, we can begin to lose our connection with our patients, our therapeutic connection. They can get impersonal virtual care almost anywhere now, across state lines, and from around the world. But they cannot easily get us and our staff in person. Real human connection that matters. 

3. Sit down and listen. I do not need to tell my DPC colleagues how common it is for the patient to return from a consult and hear that the “specialist” only spent two minutes in the exam room, never sat down, sometimes leaned against the door, stared at his or her laptop or notes, and rapidly exited with a “here’s what we are going to do” list, without ever giving the patient a chance to talk. If we do nothing else well with each patient visit, it should be that we enter the room, offer a greeting, introduce ourselves if needed, wash our hands, extend a handshake or fist bump or polite nod, sit down, with positive body language, ask the patient how we can help, and then shut up and listen. Don’t interrupt for at least three minutes. When we do interrupt, do so carefully and politely, and for clarification. Repeat back to the patient what they have said to make sure you heard it right and validate their history. If you must take a laptop or tablet in the room, use it only when absolutely necessary or as a last resort. The most important point: Shut up and listen. The patient will often tell us the diagnosis. (I take a clipboard with one sheet of paper into each room, and often I never touch it. Or I may use it to scribble down “2 x 3 mm hyperpigmented slightly raised lesion right posterior shoulder” so I can later put it accurately in the patient’s record. There is this issue of worsening memory as we get older. If you don’t understand that, one day you will.) 

4. Touch the patient. I could fill out this entire article with scientific evidence that touch is one of the most powerful actions between humans. Medicine is no exception.  Not only does a soft touch of the shoulder, or pat on the back, or application of the stethoscope, lower the patient’s heart rate and their anxiety, they are signals that we care. A sign that we are taking time and in the moment. Making a human connection. Oftentimes, it will seem silly. We know we do not diagnose coronary artery disease with the stethoscope, but for the patient with cardiac concerns, listening to their heart is powerful. Many a patient will tell you they never had anyone listen to the carotid arteries. Or look at and feel their feet. Most importantly, if the patient says something hurts, look at it, and touch it. (We all have our anecdotes. A young woman came to me early in my career with low back pain. She had seen another physician in town earlier that morning, apparently a very busy one, who had given her a muscle relaxer but never examined her. She was not better, and in fact, she was getting increasingly worse. I asked her where she hurt. She pulled the back of her jeans down just a few inches, and it was obvious she had a large exquisitely tender pilonidal abscess. I did nothing heroic. I just performed a basic. I listened, looked, and touched.)

5. Be part of the community. Whether your DPC practice is in a small town or a large city, an inner-city neighborhood or out in the farmlands, you and your practice are part of the community, part of the fabric that holds that community together, gives it hope, and gives it peace of mind. I fully appreciate it when there are circumstances and family reasons a DPC physician may not be able to live physically in the community where they practice. I think it is best, but not an insurmountable issue. You can still be engaged in the community, active in the schools, civic groups, places of worship, and local charities. Patients come to us and invest in us when they have other choices. We should give back to them – even buying our business cards from the small print shop whose prices might be higher, or placing an ad or two in the local paper, even when we know it will have limited ROI. It’s OK if you disagree. But the golden rule is considered golden for a reason. People remember how you treat them, and they remember if you value their business the same way you want them to value yours.

We are not going to win all of our games. Some people have a hard time grasping the value of DPC. They are scared to leave the seemingly comfortable world of traditional medicine and insurance. Patients will join our practices and then leave, for a variety of reasons.

But no game, or patient, should be lost because we are not hitting our free throws. As we discuss and share and debate and obsess over all the nuances of DPC – how to start, how to grow, and how to do it even better – I would encourage thoughtful consideration of these basics. I think they matter.

Now, toe the line. Take a deep breath. Grip the ball, but not too tightly. Eye on the rim. Muscle memory. Backspin. Follow thru. 

You got this.