For the past few years, I’ve compiled a summary of all of my daily journal entries and planner notes into a document I call the Yearly Review.  It helps me appreciate milestones, remove pain points, and search for new insights in the coming year.

This past month—for a variety of reasons (more on that later)—has gotten away from me, but I wanted to share some of the key takeaways from co-founding a DPC with Christina in August of 2020.

1) DPC can work

We spent the first half of 2020 preparing to open our DPC doors, working evenings and weekends on business plans and website design.  We were exhilarated, exhausted, and terrified.  For years, we’d believed in the message of DPC as a model for great care, but in the summer of 2020, just before we opened, we didn’t know what was actually going to happen.  Opening our practice meant taking a calculated leap of faith: making an abstract ideal concrete.  

Naturally, no matter how fervently we believed that DPC was the right thing, we worried: would people actually want this? Want us? Would we be rejected and laughed out of the community? Would we have to take jobs in the conventional system again, hat in hand, doing the rushed 10-minute visits?  With no experience in starting a business before this, it was easy for doubt to creep in.

But doubt about DPC is natural.  When you look around at your fellow residents all signing up for big hospital contracts, there’s comparatively little social proof in our own circles that sidestepping the conventional practice works.  In our program, we were the first residents in recent memory to try this model, and spent the latter half of our final year there honestly scared that we were wasting our time and energy on this business.   If no one around you has tried it, it’s easy to feel like an imposter.  Despite this, our time going to DPC conferences had shown us that there were already over 1,300 practices doing this in the US, and though the movement is not widely known, it is growing. 

Before, we were just preparing for a business.  But now, we actually have one.  We’ve gone from reading about Direct Primary Care to actually experiencing it: the surreal and incontrovertible evidence for us that DPC can work.  DPC is the future of primary care, and the social proof already existed, but just in isolated pockets across the nation.

2) Busy is a warning sign

As the months progressed, and patients started signing up at about 3-4 per week, we found ourselves straddling two horses.  On the one hand, we were spending increasing amounts of time handling the day-to-day paperwork that comes with onboarding established patients to our practice: sending records releases, reviewing faxes, calling specialists, and placing orders.  But on the other hand, the heavy investments of time and effort we had made initially to recruit new patients—such as by attending farmers markets and recording media interviews—had now started to dwindle.  Put simply, with all the administrative tasks piling on, we were caught between working in our business, and on our business.

Striking a balance here I found to be difficult; as work became busier, I knew the answer would involve bringing on a new member of the team, but our budget wasn’t quite big enough at the time to hire someone full-time.  By December, we were grateful for the growth of the practice, but we knew we had to make changes if we wanted to be sustainable.

Rather than using busy as a sign to work harder or faster, I considered the stretching of our bandwidth a warning sign that we needed a more effective system for processing the tasks for the day.  Otherwise, the business wouldn’t scale; we’d have less and less time for the patients under our care.

Given the stakes, we ran an experiment.  We asked: how would our workflow change if we brought on an extra set of hands, even if just for 5 hours per week?  There would be a limited downside, and the potential upsides could be exponential.  It would be an opportunity to have fresh set of eyes on our practice, coordinating logistics and streamlining our workflows.  

So we called up a fantastic nurse we worked with for years in residency, gave her a tour of the office, and asked if she’d like to be part of a new kind of health care.  She (thankfully) said yes, and after a trial run, we were so impressed by the initial results that we brought her onto our team.  The help we’ve received has freed up hours in our week, and allows us to double-down on recruitment and patient care.

3) If you don’t like something about your practice, you can change it

One of my favorite things about having a DPC practice is the autonomy.  There are no committees for decision-making or bureaucratic bloat.  If something isn’t working, we can change it, that day.  We control the hours we work, the number of appointments per day, and how long we spend with each patient.  

Because we alone control the direction of the practice, the cue-to-response time is much smaller.  Each week, we can run little experiments with tight feedback loops, and then iterate on whatever works.  

Getting a lot of add-ons on Fridays? Let’s put some buffer into the schedule, or just not schedule patients for that day.  

Feeling like you don’t have enough time to brainstorm about the business? Let’s take a few hours on Wednesdays to dream about the practice on a bigger scale.  

With DPC, no administrator dictates your schedule.

It’s true that starting a business can feel overwhelming.  We used to feel paralyzed with the million little decisions integral to getting a DPC off the ground.  But that’s the skill.  Making those micro-decisions is what we’re trying to develop as business owners: to weigh options with uncertain evidence and move decisively in one direction.  It’s an uncomfortable skill to build, but that’s also the fun part about what we get to do. With DPC, it’s your ship to command.

Though we’ve learned so much about DPC in the latter half of 2020, just knowing that it’s a reality and not just a dream has bolstered our confidence.  Having patients say yes to our practice has helped quell some of the discomfort of our initial imposter syndrome; it’s a strange logic, but by being treated as business owners, we felt more comfortable about making decisions as business owners.  We’re mindful now of how we spend our time, and quick to build systems and workflows that afford us more time with our patients.  We have the freedom to make micro-adjustments to the practice on a weekly basis.  Ultimately, though, growing a practice means recruiting a team of people who share your mission: those who can help you deliver the kind of care you’d want your family to receive.

Jake Mutch is an Osteopathic Family Physician who co-founded Defiant Direct Primary Care in Williamsburg, VA with his wife Christina Mutch, DO in summer 2020.  He writes about Direct Primary Care at jakemutchdo.com and this was originally posted on 1/30/2021 on his site.