In this episode of the DPC Pediatrician Podcast, we discuss the role of procedures in DPC practices, focusing on how they can enhance patient satisfaction and set your practice apart.
Link to podcast: Performing Procedures in your Pediatric DPC
Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr. Marina Capella, two DPC pediatricians who are on a mission to share our love of direct primary care with you. Hey, everyone. Okay, today in DPC Pediatricians, we’re talking about procedures. And I think in general, pediatricians are usually, as a whole, a little procedure shy.
0:23
And I always was kind of of the mind of like, it’s kind of fun to do procedures. I don’t know. I’ve always liked doing procedures as a way to just kind of have a little bit of risk and a little bit of excitement and use my hands and brain in a different way.
0:37
And so procedures has always been something that I’ve really enjoyed doing in pediatrics. There aren’t a ton of different procedural things, right? But in DPC, you can kind of cultivate your interests even more so than in the regular fee-for-service. I remember in previous jobs where it was like, hey, I want to do this.
0:54
No, you’re going to send those to the ear, nose and throat doctor. Or no, we’re just going to send them to the hospital for that. And I’m like, but I can do this and I would enjoy it. And so that’s always been something for me that has been like an interest is cultivating my procedural skills.
1:11
Now, not all of them are that much fun. I used to do toes, like ingrown toenails.
1:16
Uh-huh.
1:17
which I have abandoned since starting DPC, but everything else I do. So what about you? And then we can talk through kind of the bullet list of the different procedures. What’s your tolerance slash interest in procedures?
1:29
I love procedures. In fact, I was tempted to go into surgery as a med student, but for various reasons, I decided that wasn’t the best maybe for my mental health. But yeah, I really like procedures. I love working with my hands. One of my hobbies is sewing and doing that kind of intricate work. So I love procedures.
1:48
I actually, opposite of you, I learned, I taught myself to do ingrowing toenail removals when I started DPC and now offer them, whereas before I didn’t. And they’re really gross, but it’s very satisfying too.
2:01
They are gross, but they are satisfying. Yes, that’s true.
2:04
So yeah, I offer procedures and I enjoy offering them because why should someone have to go to a podiatrist? Why should someone have to go to a dermatologist? to get a work for an offer. Why should someone have to go to some really expensive specialist get to get some
2:18
of these simple procedures done or an urgent care in our case, right? As primary care doctors, do they really need to go to an urgent care to get that small laceration fixed? I, before I opened my DPC, I worked in pediatric urgent care for about three years.
2:34
And so I was coming out of that pediatric urgent care world. And I had a lot of experience with laceration repairs and all sorts of like injuries. And acute illnesses. So I wanted to definitely like keep doing the things, at least offering the things that I had been able to offer in urgent care.
2:52
I think that is such a good background for being comfortable with all the procedures. And I think that’s one of the things that often is the issue is the lack of comfort with stitches or things like that. Because if you come, especially from the fee for service world, where they just got sent to the ER,
3:08
they couldn’t work you into the schedule, you’re booked out for weeks and weeks. So of course you can’t staple someone’s head, then you’re not going to have a lot of comfort with that. But I think that if that’s something that you like and can cultivate. Then it’s another way. We talked in another episode about one-time visits.
3:22
People know if they have stitches, like we’ll do them. And I’ll be like, yeah, just send them on over. So people know that. And they’re like, well, my kid has stitches. This isn’t our regular doctor. We don’t really want to go to urgent care of the ER. Let’s text them and see if they’re available.
3:36
And then you can decide if you’re available for that or not. So, okay. So what all procedures do you do then? You said stitches.
3:45
Yeah, so I offer stitches and like dermabond. So any small laceration repair, right? I did initially offer circumcisions, but then my volume was so low that I just decided after actually just a few months ago that I would stop doing them because I didn’t feel like my skills were being kept very up to date.
4:05
Plus also I have a lot of families that refuse vitamin K for reasons that I don’t completely understand. And I just thought it was better to say no, like I’m not going to take it. I mean, I can say no, but sometimes they, I don’t know, I don’t always trust that they’re telling me.
4:21
complete truth with some of these hesitant families. So I said, you know what, I’m just not going to take that risk and I’m not doing it often enough. I’m just going to sell my supplies and, and stop doing that. I do the ingrown toenail removals. I do.
4:33
Do you do the ingrown toenails for adults? Like, I feel like that’s not a very, maybe like teenagers. I just don’t see teenagers. Usually it’s mostly teenagers. Okay.
4:42
Yeah. It’s mostly teenagers. I mean, I’ve seen like two babies in the past with ingrown toenails. toenails but they’re so mild that just like warm soaks and other things are going to take care of them yeah so it’s usually the teenagers that are getting those ugly toenails What else do I do?
4:57
I do ear piercing like you do, although I don’t do it that often. I have the supplies, but I don’t market it very aggressively. So I don’t do it too often, but it’s really fun. I wore freezing. So I have a tank of liquid nitrogen.
5:09
I bought the smallest one I could get and I have to refill it. Maybe I don’t always keep it full. I sort of fill it when I need it because otherwise it would just be money that I don’t need to spend.
5:21
That would literally evaporate your money.
5:23
Yes, exactly. Those are the procedures I can think of off the top of my head that I do.
5:29
I think our list is pretty similar. So we do sutures and staples and dermabond and things like that. One of the nice things about DPC is you know the family so well that you can like kind of know if you’re gonna open that text message at 7.30 at night.
5:44
Because I had a family that they just had a new baby and one of their kids had fallen and needed a staple. And sometimes I would say, just go to urgent care. But this family, I knew that they just had a baby and I was already at home.
6:01
And we were just playing outside and I was like, just come over. I mean, I have a stapler at home. And so they just pulled up into the driveway and we stapled their head back together. I don’t always do that. And I think that’s something that is important in DPC,
6:14
just like set your boundaries and then know when to enforce your boundaries. Like my patients do not expect if they have a laceration on a Saturday afternoon that I’m going to leave whatever we’re doing as a family to come sew them up.
6:26
But it wasn’t a big deal for me when I was like, we’re just playing outside anyways. This will take two seconds to throw one staple in and then you can go back. Like, that’s not a big deal to me. Let’s see. What else do we do? We do.
6:39
Oh, you mentioned phrenotomies also.
6:41
Well, phrenotomies. Yeah. So phrenotomies and circumcisions is something that we do. The phrenotomies, I typically like to do those in the hospital. So when we do rounding on babies, we’ll just do them right there at the bedside that parents really like. And then, I mean, if it wasn’t severe enough that we’re not sure,
6:56
we’ll watch it for a few days and then just do them in the office. And that was something that I just trained on during residency and I like doing. And I think that parents really like just the ease of being able to do that.
7:06
circumcisions we do in the office only end in the hospital too but in the office we started offering them because people were sending us their bills from the hospital and i was like it only cost me like 300 like a week physician charge it’s like 300
7:20
for a circumcision the hospital bill was like 1700 for the room and the supplies and all those sorts of things and i said we can do it for the same price, like not for, not for $1,700 for $300. Like the supplies are mostly reusable and not expensive at all.
7:37
And so we started offering it not because we wanted to really do them in the office, but because patients were spending so much money in the hospital for the exact same experience. It was just outrageously expensive in the hospital. And so we do them in the office.
7:51
If they, if they didn’t get vitamin K, then we wait until a month and just do them then. Because I agree with you that I don’t always know what to believe. And I can do a circumcision on a one month old nice and easily.
8:05
And then I feel like their clotting system is as good as it’s going to get anyways. And so I feel comfortable with that. What else do we do? We do a lot of ear piercing. That’s something that we advertise and as a way, both as a revenue generator and more foot traffic is ear piercing. And
8:19
frankly, I just think it’s fun to do. Like the kids always love it. It’s always a good experience. And so that is easy and quick to do and fun for me. What else did I say that we do? Those are the biggest procedures that I can think of that we do on a regular basis.
8:34
I can’t say that I’ve even drained an abscess since I’ve been in DPC, but I would if I had the opportunity.
8:40
Yeah, exactly. I think I’ve only done one. So yeah, I mean, And that’s pretty darn simple to do. So yeah, with procedures, we both happen to enjoy doing them. So we offer them. I would say that it’s going to be more beneficial to your patients and the families
8:55
you serve if you are able to offer at least some of these. You don’t have to offer ear piercing, but And if you offer simple staples and simple dermabond, at least for laceration repairs, not everyone feels comfortable with sutures. And I would say having worked in urgent care,
9:11
a lot of the comfort level there has to do not just with you, but like having adequate anesthesia, for example. So we used let gel, which is lidocaine, epinephrine, tetracaine. And it was wonderful, but it has a short half, a short shelf life, excuse me. And so, you know,
9:29
sometimes acquiring it and then having to pay for it and then having it expire, if you’re not going to use it, I can understand why not everyone would want to do that. And, or you might want to wait until you have a high enough volume of patients in your practice to
9:43
take on that expense so that and then also you know the nurses in urgent care were really skilled at holding the patient so if you’re by yourself and you don’t really have someone reliable helping you out to hold a patient or the parent is not able
9:58
to do it very well you know that’s something you want to consider as well but it’s really nice to at least be able to offer dermabond in your clinic and staples. Staples are so simple. You don’t, usually in urgent care, we didn’t even use let gel for staples because they’re so fast.
10:13
And honestly, the pressure is what hurts. And so even if you lose use let gel, it’s not really going to help that much because you have to push kind of hard to get it positioned right. And it’s really fast, though. Yeah. And so so really, it’s up to you if you want to offer those things.
10:28
But it’s nice. It’s a nice perk. And it’s going to help patients and families to see the value of what you offer. It’s like, wow, like my doctor can do all of these things. And how convenient is that?
10:41
It does come down to convenience, comfort level, and like the desire to do it. I don’t think that, like you said, you don’t have to do those things. And I don’t think a lot of patients expect them because most practices that aren’t urgent care don’t offer like walk-in laceration repair.
10:57
So you can set yourself apart in that way, but you also don’t have to because people aren’t expecting just to be taken care of in that way on demand. What about cost? Do you charge separately for those or how does that look for procedures in your practice?
11:13
Yeah. For the vast majority of procedures, I don’t charge extra. I think when I was offering circumcisions, that was the one exception and then ear piercing since it’s a cosmetic procedure. Those were the two exceptions of what incurred additional charges, but the rest of it, you know, it’s part of kind of this routine pediatric care.
11:33
So I just include it in my cost, but You know, you have to if you are going to be, you know, stocking sutures, which can be quite expensive and dermabond, which can be quite expensive and let gel, which expires. And, you know, you’ve got to factor that into your cost of operations and maybe price yourself a
11:50
little bit higher in order to be able to offer those things.
11:53
That’s exactly my take on it, too, is we don’t really charge for procedures. other than ear piercing and circumcision, because not everybody can benefit from those and not everybody wants those. Whereas if like everybody can benefit from us being able to staple their kid’s head, because that’s not something they choose. It’s just a fact of life.
12:12
And otherwise they’re going to have to go somewhere else. And frankly, patients always talk it up when they’re like, They got us in right away. They stapled his forehead. That’s something that comes up at the water cooler of parenthood quite frequently. It’s like, oh, did you have to go to urgent care? No, our doctor just did it.
12:27
I’ve done them. I kind of keep staples in my car. And we were at dance practice for one of my daughters. And somebody texted and their kid just needed a staple. Staples are the best ones by far to have available because kids always need staples. And I said, I’m sitting at dance right now.
12:43
Do you, can you just swing by here? And we just did it in the parking lot and it worked out perfect. And so people talk about those things when they have those special unexpected moments where they get that special attention and care. Otherwise we don’t really charge for procedures either other than the stuff that
12:59
not everybody can benefit from.
13:00
Yeah. Yeah. Yeah. Well, I hope this has been helpful for you if you are considering whether to offer procedures in your DPC practice or not, or maybe increasing the amount of procedures you offer and what’s right for you. So thanks for listening.
