Marina and Phil discussed the transition from a traditional fee-for-service pediatric practice with constant on-call demands to their current practice where they set clear boundaries for after-hours communication. By managing expectations and providing structured responses, they ensure availability during office hours while avoiding middle-of-the-night disruptions, resulting in a manageable work-life balance and appreciative patients.
Link To Podcast: Do I Have To Be On Call 24/7?
00:00.30
marinacapella
Welcome back? Oh sorry, yeah, we are recording. Okay, welcome back. Everyone I glad you’re here to listen to another episode of dpc pediatricians Today we’re going to talk about this question that we often hear. Among the dpc pediatrician community which is do I have to be on call Twenty four seven a lot of people when they’re thinking about the idea of opening up a pediatric dpc they worry about this. They’re like I don’t want to leave 1 job where I feel burned out. And then go to another thing where I’m just going to be burned out because parents are going to be texting me and calling me twenty four seven how do you answer that question Phil that when people ask that.
00:39.50
Phil Boucher
So when it comes to that you know I think that is one of the main things that parents are were not parents. Pediatricians are worried about when it comes to starting a direct primary care practice because they understand the promise which is better availability patients can text you. Patients can get a hold of you and they can get in for sameday visits and all of those sorts of things and so then they worry well that means that I have to be like available twenty four seven for families and I don’t really want to do that and I like that we have an answering service or we have roadblocks that prevent. You know me from getting text messages.
01:09.65
marinacapella
Um.
01:18.10
Phil Boucher
When I’m on a date with my spouse or sleeping or at the pool with my kids or whatever it might be um when I first started so in my previous life in a fee for service practice we would there were 10 Pediatricians we would rotate who was on Call. We had an answering service and a nurse triage line that would answer the phone calls and give the Tyland all doses in the middle of the night and tell people to go to the Er or make an appointment or call in the morning or those sorts of things and so when I started I didn’t really know what to expect when it came to ah how often our parents texting in the evening. What are they.
01:55.49
Phil Boucher
Expectations and I think I walked into it with the idea of I’m going to put these boundaries in place and I’m going to try and hold to these boundaries and then see how parents respond because yes, if a patient calls it 2 in the morning and their kid is Croupy. Well sure I could go in at 2 in the morning to give them a dose of desometzone but by and large they’ll do all of the usual stuff for croup and they’ll be fine until the morning and then we’ll get them seen like that is a normal expectation. Nobody’s expecting me to actually at 2 in the morning in my slippers and pajamas go over and give them you know. Ah, six milligrams of dexometyzone or something like that. So I’m going to try and avoid doing that because I don’t want to do that and I don’t want to be woken up from my sleep or not know when I go to sleep if it’s going to be a middle of the night running to the office to do stitches for the kid that fell out of their bunk bed or something like that ah didn’t want to do that have six kids.
02:33.58
marinacapella
Ah.
02:46.91
marinacapella
Ah.
02:49.74
Phil Boucher
Don’t want to be go back to being a resident of like constantly being on call and just not knowing like is the pager going to go off tonight sort of vibe that everybody remembers from the days of residency and so what I did was I said okay here’s our hours. We’re super available during those hours.
03:00.17
marinacapella
Aha.
03:08.49
Phil Boucher
Text if anything comes up during those hours and we will get back to you within an hour it will be lickty split. We’ll get things taken care of if it’s after hours. What’s gonna happen is you’re going to get a text message right away that says um, hey we’re not open right now but we’re still available to help.
03:14.69
marinacapella
Here.
03:28.36
Phil Boucher
Leave a message here and we’ll get back to you in the morning if you want to make an appointment here’s the link to schedule an appointment so that you can get in in the morning or if you’re not sure what to do here’s the number to call and so parents were given that right away of okay how much of an emergency is this let me as the parent decide and what that did is it totally. Ah, set the expectation of we’re going to get back to you but we’re not going to get back to you right now and then when people do text in the evening I’ll typically kind of keep an eye on it like my watch buzzes until I take my watch off because the battery died in the evening. Ah I’ll keep an eye on it and if it’s something that is easy and takes less than 30 seconds to just.
03:54.87
marinacapella
Um, man.
04:02.85
marinacapella
Ah.
04:08.12
Phil Boucher
Ah, you know record a little Siri reply or it’s something. That’s super straightforward then I’ll typically reply if I have a moment but I don’t make that the expectation and then parents are always excited when they do get a reply or maybe maybe they’re not excited but they’re appreciative. Oh it was seven thirty I wasn’t expecting a reply to the morning and he told me that I can do honey and cool night air and the barky cough should get better and that they’ll see me tomorrow perfect I’m set for tonight I’m all good and so that has been our approach when it comes to ah am I available Twenty four seven not really
04:36.89
marinacapella
Ah.
04:44.58
Phil Boucher
I am in 2 years I have we have over 560 patients and I’ve never been up in the middle of the night talking with a patient nor going in in the middle of the night to do anything for a patient. Um, one time somebody had texted and my dogs woke up and I had to let them out and I looked at spruce which is the.
04:44.89
marinacapella
Ah.
04:54.17
marinacapella
The heart.
05:03.90
Phil Boucher
Texting platform that we use and it was something where it was a new baby sort of feeding question and I was up with the dog. So I texted back and I said hey I wouldn’t have seen this to the morning but I was up with the dogs and so here’s what to do and they were super grateful for that Otherwise people just wait until the morning and when you don’t have.
05:17.84
marinacapella
Ah.
05:20.88
Phil Boucher
2000 plus patients and be or be in a practice of 15000 patients or something like that. There’s just fewer things that come up in the middle of the night once everyone’s gotten tucked in so that’s been our long form of our perspective. But what’s it been like for you.
05:21.38
marinacapella
Now.
05:32.19
marinacapella
Ah.
05:37.12
marinacapella
Ah, yeah, um I did not like the idea of promising twenty four seven from the beginning I did not like that language I know that some pediatricians choose to use that language on their websites and in their marketing materials I say seven day a week access and when.
05:42.12
Phil Boucher
Um, yeah.
05:48.93
Phil Boucher
The her.
05:54.78
marinacapella
Parents enroll I explain to them look I need my sleep like anybody else and I’m a deep sleeper and like you can try calling in the middle of the night but I probably won’t answer so this is what you do If. You have an emergency in the middle of the night. I Also set that expectation like you do if you text me during the day I’ll reply I do give them sort of a broader range I say you know if I’m awake and I and I’m not in the middle of seeing patients or something else I’ll I’ll respond Um, if somewhat. Although so I do get quite a few texts in the evenings.
06:28.80
Phil Boucher
Yeah, yeah.
06:30.72
marinacapella
And parents are really appreciative when I reply but if it’s something that is um, very minor or like I need to schedule an appointment or something I might just reply with I’ll reach out tomorrow to do that right? to kind of set that boundary and respect that boundary and train them.
06:41.52
Phil Boucher
I right? Totally I think you can set that boundary and it makes a huge difference of like like you said training patients to be like oh well this is obviously not an emergency we can address in the morning.
06:54.90
marinacapella
Yeah, that being said, sometimes I find it easier for me to just deal with it right? then and so it really depends on the context if I have other stuff that I’m trying to do that evening.
07:01.17
Phil Boucher
Number.
07:08.00
marinacapella
Um, I might say I’ll reply tomorrow. But then I have to add it to my to do list. So it’s 1 more thing on my plate for tomorrow. So if it’s easier for me and I have 2 minutes then I’ll just deal with it right now or if they want to schedule say okay I’ll send you a scheduling link my system has a self-s scheduling ability for existing member. So that’s really nice. Ah.
07:12.56
Phil Boucher
Me.
07:24.20
Phil Boucher
Um.
07:27.48
marinacapella
But yeah I I don’t like the language twenty four seven however I know some pediatricians within our community who do promise that and they don’t mind getting up in the middle of the night. But what they’ve said is it happens once or twice a year. It is not something that is happening every week every night every month even
07:36.50
Phil Boucher
Right. Right.
07:47.16
marinacapella
It’s a very rare occurrence where there’s a true emergency that they have to go do a house call in the middle of the night for or take a phone call.
07:54.24
Phil Boucher
1 of the things that I never really took into consideration because I in my old practice like we were seeing patients till 7 or 8 at night like they the the practice was open until 7 or 8 at night that was a function of being so busy during the day that.
08:10.91
marinacapella
Yeah.
08:12.78
Phil Boucher
Those sick patients that had a fever at lunchtime. They couldn’t get in until 7 or 8 at night if not the next day and so then it’s like well there’s a huge backlog of patients. There’s patients that haven’t been seen that have issues and so then those bleed over into the evening well in direct primary care. When patients have an issue. They just text us and then if they need to come in. We’re able to say come on over sure we’ll see you or let’s get something on the books for tomorrow there isn’t that huge backlog. Ah there isn’t a logjam of patients that are needing things and so things at least in my experience have. Played out by four o’clock five o’clock six o’clock where there aren’t these acute emergencies that need to get in kids have fevers and they say hey we have a new fever. It’s seven o’clock at night you know should we come in tomorrow. Well your kid is 2.
08:49.69
marinacapella
Now.
09:02.27
Phil Boucher
There’s lots of stuff going around daycare try Ibuprofen and let me know tomorrow or the next day if things aren’t going better and we can check them out like it’s just you don’t have that volume pressure that then leads to just like constant messages and grasping for whatever health care they can get if kids are sick.
09:07.84
marinacapella
Ah.
09:18.24
marinacapella
For her.
09:21.37
Phil Boucher
They’re going to be sick and they’re going to be stuck home from day daycare or school. We’re able to get them in the same morning or the same afternoon and so they don’t build up for days and days that’re not dealing with that backlog and constantly trying to play Catchup. We’re caught up and so then we’re home for dinner on time. With most things taken care of and then you’ve got the stragglers that straggle in in the evening that then you can address like you said with a quick text message or you know reassurance or something along those lines or send them to schedule their appointment for the next morning it just doesn’t create as much volume. There isn’t as much volume pressure. And so it’s not that there’s so many evening emergencies.
10:01.72
marinacapella
Yeah, your ah that point also reminds me that you know and in a typical fee for service. Parents only have five or ten minutes with you and so they have a lot of residual questions and and so that that creates part of that problem.
10:11.51
Phil Boucher
Ah, right.
10:18.16
marinacapella
And those anxieties whereas in Dpc you have a little more time to spend with your patients and so you can make sure that all of their questions are answered adequately at the visit and so that decreases the amount of questions that they have outside of the visit as well. Um I remember in my.
10:21.33
Phil Boucher
With him.
10:36.28
marinacapella
In my old practice having that anxiety of when the weeks that I was on call um getting those phone calls in the evening or in the middle of the night. There was a nurse triage system but certain things would still come through and so.
10:47.84
Phil Boucher
Right.
10:51.11
marinacapella
I had to and I always dreaded it because I didn’t know the patient 99.9 percent of the time I had this was a complete stranger to me and in pediatric dpc. You don’t have that issue. You know your families pretty well and so you know.
10:54.70
Phil Boucher
Over.
11:08.18
marinacapella
You don’t you don’t have to go log into your laptop and look up some record of a stranger. It’s much easier to answer the questions because you remember the families. You know the families you have a relationship with them and so it’s much easier to answer those questions and there’s less anxiety on our part to do that.
11:10.52
Phil Boucher
Right.
11:16.59
Phil Boucher
Total.
11:22.59
Phil Boucher
Yes, that makes such a difference too is because like you know if so-and-so is reaching out. It’s really serious or this parent has a lot of anxiety and so I know how to address that and help them.
11:30.16
marinacapella
Here.
11:37.60
Phil Boucher
Rather than oh I don’t know anything about this kid I don’t know if they were in the office this week if they have an underlying immune disease or heart disease or anything you know all your patients by their first name and you know their parents too and so you know exactly like what they’re going to need or why they’re reaching out to the specific time I have 1 dad that tends to call and I’ll see a missed call at like seven thirty
11:50.55
marinacapella
We have.
11:56.26
Phil Boucher
And they have like 7 kids and it’s always because one of them needs stitches at seven thirty at night I don’t know why that is like that’s the witching hour at their house for kids need stitches or something like that. So I know if I see mis call from this specific dad I know exactly what it’s going to be and I will say okay take me a picture and then I’ll tell you what to do.
12:00.32
marinacapella
Oh no. Ah.
12:05.51
marinacapella
Ah.
12:15.10
Phil Boucher
Um, because it’s going to be somebody fell down and probably needs stitching or can wait till the morning or it doesn’t look that bad. Let’s just you know, put some ice on it and see but um, you get to know your family so it makes it so much easier to handle those things as they come up what about vacation Tell tell me like.
12:15.67
marinacapella
Yeah, ah, ah yeah, yeah.
12:29.30
marinacapella
Ah, yeah, yeah, you should definitely.
12:34.27
Phil Boucher
What about vacation for you because we were just recently together at the dpc pedd pediatric dpc mastermind in Austin ah, and so there were a lot of pediatricians there that were managing things from abroad without having the ability to do hands on.
12:41.44
marinacapella
Ah.
12:47.81
marinacapella
Are ah.
12:49.69
Phil Boucher
Um, ourselves included so what is vacation? What is conferences? What are those things? How do you handle that so that you can still do those fun things and and not feel like you’re tethered to being in a certain radius Twenty four seven
13:00.20
marinacapella
Yeah, that’s where again setting expectations with families from the time of onboarding comes in I tell my families to say look I like to go to conferences and and continue learning and and once in a while I take vacation. So I’m typically gone about 3 to four days a month to some sort of.
13:11.16
Phil Boucher
Um, enough.
13:18.74
Phil Boucher
Um, yeah.
13:19.38
marinacapella
Conference or cmme something or vacation sometimes and so I tell them look in the case that I’m gone I’m still available via text message so you can expect a response within a few hours if you text me if I think it’s something urgent where your child needs to be seen. Then I have a backup pediatrician I share my office with another pediatrician who has her own business model. So we cover for each other when we’re gone which is fantastic. Um, so I I explain that to them and then I say sometimes if I’m gone for longer if you know once in a while I go. Um.
13:45.74
Phil Boucher
Um, right.
13:57.20
marinacapella
Outside of the country for vacation then I might not be available for a week or so and I will let you know in advance if that’s going to happen so that you can prepare and you can get all your needs met before I leave so I do leave a lot I like to go to conferences like I mentioned and um.
14:01.83
Phil Boucher
Um, yeah, totally.
14:16.54
marinacapella
I Just tell my parents that so that I make sure that they’re okay with it.
14:19.33
Phil Boucher
You do that and they are okay with it right? and I think that that’s like the worry is they’re going to be so mad if I leave or something like that. Well if you give them notice then they’ll know what to expect and they’re not going to be surprised when you say oh I’m out of town. You’re going to have to find somewhere else to get your kids’ ears looked at.
14:22.37
marinacapella
Yeah. Yeah mm.
14:37.39
marinacapella
Yeah, okay.
14:39.50
Phil Boucher
Oh yeah, she’s on vacation and then you know what they’re going to do. They’re not going to bother you and they’re also going to ask about your vacation because you have that relationship with them and they’re excited that you’re going to this place or that place and you know want to discuss it with you and I think that’s the fear that Pediatricians have is they have to be always available. Well if you set expectations. Well.
14:45.87
marinacapella
Ah.
14:48.94
marinacapella
Yeah.
14:58.72
Phil Boucher
If you if parents know what to do when their kid is sick and if you communicate with them when you’re not available then they’ll make other plans because I think one of the things that Pediatricians worry about is well they’re going to be mad at me and they’re going to go back to the other place because.
15:02.69
marinacapella
Ah.
15:05.11
marinacapella
Yeah.
15:15.70
Phil Boucher
I wasn’t available for them on a Saturday afternoon when my kid had their dance recital. No, they’re going to say well even though they’re not available now or even if I had to go to urgent care or something like that now it’s still three miles ahead of where it used to be when I would have to call and leave voicemails and play phone tag.
15:15.34
marinacapella
Ah.
15:23.53
marinacapella
Yeah.
15:34.22
Phil Boucher
And sometimes they’d be able to get me in and oftentimes they wouldn’t be able to get me in and I had to go to urgent care anyways, like it’s already so much better that it’s okay, if occasionally I have to do the urgent care dance or something along those lines at the worst because 97% of the time. It’s 300% better than it used to be.
15:38.29
marinacapella
Yeah.
15:53.25
marinacapella
Ah, yeah, and that actually reminds me of the story so we were both at the pediatric dpc mastermind in Austin a few weeks ago and the morning that I was getting ready to leave like I was literally like showering and packing my bags and ready to head to the airport within an hour and um.
15:53.48
Phil Boucher
I.
16:09.88
marinacapella
2 families texted me that morning saying their child was sick and I thought oh no, this is exactly what I was dreading. Let’s see what happens and and there was no way that I could see them right I needed to get to the airport. So one of them was a baby at three month old who had cold symptoms and the mom was concerned.
16:17.57
Phil Boucher
Um, yeah.
16:28.16
marinacapella
And I said I’m so sorry if you want I Can you know we can do a quick phone call and I can see what you can do and she said and I explained that I was leaving town for a few days for a conference and she replied so graciously. She said oh don’t worry about it at all. We’re totally fine taking her to urgent care and and I said Okay, wonderful.
16:35.40
Phil Boucher
Right.
16:47.60
marinacapella
I’ll follow up with you later just to see how everything went so I followed up with her that evening and she had taken her baby to urgent care and the baby was diagnosed with Rsv and I said okay what did they do? They did nothing right? They didn’t even really give her great advice. So then I was able to text back and forth and say okay I’m going to send in an order.
16:59.95
Phil Boucher
Um, right.
17:07.24
marinacapella
For the outpatient respiratory clinic where you could go. You can go once a day and get your baby suctioned there and she said oh thank you so much and we talked about suctioning. We talked about other home care measures and yeah er precautions and she was so so grateful that I had taken just you know five ten minutes that evening to.
17:09.76
Phil Boucher
Um, oh yeah, you told me about this? yeah.
17:18.80
Phil Boucher
Right.
17:27.90
marinacapella
Communicate with her and then the other family responded in the same way. Their child had ear pain and they said oh don’t worry about it. You know, um, we’ll call her aerial Ariel is so sad that she’s not going to get to see you but we’re completely fine taking her to urgent care. Enjoy your conference right? So it was just such a it was.
17:44.81
Phil Boucher
Ah, yeah.
17:46.95
marinacapella
Such a nice feeling to be like okay they’re not mad at me. Um, that we have this relationship. They appreciate me. They love me. Um and they know that they can still text and ask questions if anything comes up.
17:56.33
Phil Boucher
Totally I think that is huge and I think that’s really like the the total learning point from this whole discussion is first of all, they love the model. They love you as a person and the care and service that you provide they are understanding and you know your patients and so.
18:00.93
marinacapella
Flip.
18:15.74
Phil Boucher
If you put those expectations and those boundaries in place and you reinforce those and you teach those and you train those on a regular basis with the patients. You do not have to feel like you are 24 7 3 65 at their beck and call. But when you are available. You get to have these really special unique ways of caring for families. That just you can’t find elsewhere outside of dpc.
18:38.80
marinacapella
Definitely And once in a while if you do happen to encounter a family or you know a parent who really is demanding and doesn’t respect those boundaries then they’re not a good fit for your practice and you have the ability to say you know what. I Don’t think this is going to work out I can’t meet your needs politely goodbye right? So That’s another thing that you could do? Yeah yeah, um.
18:59.41
Phil Boucher
Or or theyll self select that this wasn’t the right fit for me I wanted something that does not exist and or I want somebody that can you know come on their helicopter to ah you know, ah swab my kid for strep at my my house and that.
19:12.53
marinacapella
Yeah, yeah, yeah, exactly.
19:14.35
Phil Boucher
Maybe that exists great I’m sure it costs a lot more but it wasn’t the right fit so they’ll they’ll find their way out too. But I I think it’s helpful for especially those that are kind of on the cusp or thinking about it to hear. Okay, you can do this and you can pet those boundaries in place and patients don’t leave and patients don’t leave because you.
19:30.28
marinacapella
Better.
19:34.27
Phil Boucher
Ah, were out of town or they had to go to urgent care or those sorts of things like just knowing that hopefully makes a huge difference for those that are considering it to realize like you don’t have to be everything 24 7 3 65
19:44.29
marinacapella
Absolutely couldn’t agree more. So hopefully that answered your question if you had it on your mind of do I have to be on call Twenty four seven as a dpc pediatrician the short answer is no.
19:56.10
Phil Boucher
And the long answer that 18 minute answer is also no.
20:01.72
marinacapella
Ah, exact all right take care everyone till next time.
