In this episode, Dr. Phil Boucher and Dr. Marina Capella discuss their daily routines as Direct Primary Care (DPC) pediatricians. They share insights into their schedules, patient interactions, and how they maintain work-life balance while providing personalized care.
Link to podcast: A typical Day in our DPC Office
Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr.
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Marina Capella,
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two DPC pediatricians who are on a mission to share our love of direct primary care with you.
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Welcome everyone to another episode of DPC Pediatricians. Today we’re going to be sharing what a typical day in our pediatric DPC practices look like. Of course, this is going to be something that’s very variable, but at least you can get a little glimpse into the world of our daily schedules at Frontier Pediatrics and Healing Art Pediatrics.
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And of course, there’s a lot of customization to it. So listen to what we say and then say, what would I like my ideal day to look like? And you can decide what’s right for you. So Phil, start us out. What does a typical day at Frontier Pediatrics look like?
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I mean, I think I would love to have had the music of One Short Day in the Emerald City, you know, playing in the background of this as we’re like introducing this, because I feel like that would have been some good music if we were that thoughtful. I think, okay, so for me,
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when I was designing my schedule, the most important thing was leaving work early and on time, because I like to be, we have six kids. I like to be home with my family. I like to make dinner with my kids. And that was really important. So kind of my whole day was
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centered around, how can I make sure that I leave by 4.30? Three years in, I can say without any caveats that we leave, our whole team leaves at 4.30. So we’re all gone by then. And the thing that I love about that is it’s not, hey,
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we’re leaving at 4.30 and you have to go to urgent care or no, we’re closed and we’ll have to get you in in two days. That’s 4.30 with everybody taken care of for the day, having no loose ends, not tied up. And the reason that we’re able to do that in direct primary care is because we have
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such a small patient panel that it’s easy to say, yeah, can you come over at two? Or yeah, we can squeeze you in even if we’re kind of full for the day. Like we can do those squeeze-ins because we don’t have five patients per hour that we’re seeing or something along those lines and the
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nice thing is too that patients are sick when they wake up in the morning typically if they need to be seen that day right it’s not like the kid that gets a sore throat at 3 30 needs to be seen that day to get the strep swab I tell people that
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it might be negative still because you know we’ve got to give it a little time if they wake up and they’re sick they already know that they’re gonna be able to get in during the day and so that’s kind of the like backstory behind my schedule
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uh-huh
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On the front end of my day, I like to help get our home off to a good start for the day. We homeschool. Our oldest is in high school. So I drop her off at high school and then I go to work. And the first thing that we do is we kind of catch up on text messages.
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I try and put nice boundaries in place that I kind of stick to when it comes to after hours messages i will usually when i get up in the morning just like quickly look and see if there’s anything urgent that that
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needs to be addressed but if it’s not an emergency that they need to get in then we just leave it to eight o’clock and we catch up on spruce messages when we get there checking in on people that had texted overnight or were in yesterday and then you
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know anything like figuring out what we need to do with anybody that’s sick this morning where we’re going to put them on the schedule that sort of thing At 830, our team has a huddle where we all come together and we talk through the patients for the day and anything that’s going on.
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So we look at all the schedules. There’s myself, we have a PA named Lindsay, and then we have a part-time nurse practitioner named Clara, who’s in the office through four half days per week or so. And so we look at the schedule and we see who’s coming in and what’s going on with them.
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This gives us the chance to talk through those things, catch up on anything. If I saw some messages in Spruce that might not have gotten documented.
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Mm-hmm.
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And Marina can imagine how often that happens, I’m sure. You’re like, hey, actually they did text in yesterday about the vomiting and I sent in some Zofran, FYI, you’re seeing them this morning, that sort of thing. And then just go through anything that’s going on with them, make sure that they’re getting vaccines,
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that they’re set up in VaxCare, all the different things that go on that we wanna make sure that makes for a smooth day. So our huddle is like 30 minutes. to talk through our day, make sure that it’s going to be smooth. And it usually doesn’t actually take 30 minutes.
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It usually takes about 15 and then we’ll chat or we’ll do this thing called body doubling. Have you ever heard of body doubling, Marina?
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I have, but how do you use it?
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we all just sit around, we’ve all got our laptops in our conference room. And then like, we don’t, it’s not like a formal sort of thing, but we’ll be like, okay, go team. We’re done with the schedule, but then nobody gets up and leaves. Everyone just is like sitting there typing on their laptop.
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So we consider that some body doubling time where we’re all kind of just like still getting stuff done. Presence.
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Right.
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Uh, then I typically will see patients about every half hour throughout the day. And yeah, that’s kind of the boring part is like seeing the patients. We have a mix of sick visits and checkups and then sometimes specialty visits things. So one thing, a couple of different things that we do, we do a lot of ADHD evaluations.
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We do a lot of pandas evaluations, uh, And so we’ll sprinkle those throughout the day. Myself and Clara do autism evaluations. So sometimes we’ll have those thrown in. We try and throw in evaluations like in the middle of the day, like closer to the lunch hour. So that if there’s sick patients that need to get added on,
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we have room to squeeze them in the mornings and then have more room in the afternoon for adding on sick patients as needed. But it varies dramatically from a day-to-day basis. If we have patients in the hospital, so newborns or if somebody gets admitted to the hospital, we don’t see them like we’re not the admitting doctor,
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but we do go visit them. And so newborns will go visit either throughout the day or on my way to work. Like I swim by the hospital after dropping my daughter off at high school and then come to clinic. That’s the. big picture of our day-to-day schedule.
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In terms of the number of patients I see on any given day, it’s probably between five and 10. And the same for my team. I think when we’ve looked at the numbers, you know, you probably see about 1% of your panel per week in a pediatric direct primary care practice. So we have 600.
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So that’s 65 appointments per week, which divided by five for days is like eight to 15 visits per day.
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Yeah. Tell me a little about your seasonality. I mean, obviously in pediatrics during the summer, less illnesses during the winter, a lot more illnesses. Flu has been pretty bad this year. So how does that work for you? Do you ever have days, especially in the winter, where you just can’t see everyone who needs to be seen?
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We have not had that happen yet.
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Good.
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I think my team is very, we are all very quick to pitch in. And so if patients need to be seen, we just find time. And we know our patients so well that like, we know the parents that, you know, just want to come in, get their weights, measures and shots and get out.
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So we know we can, we can subtract a little bit of that appointment slot because we know we’re not going to use it all. And then we know the ones that are going to take a longer time. So we don’t add somebody on right on the back end of those as well.
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And then so much of it can be managed virtually, right? With text messages or a voice message or a video or a quick telemedicine visit that those things take up so much less time than when patients come into the office. that that allows them to have a lot more margin to where even in the sick season,
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it’s not like every patient that calls in and has flu symptoms needs to come into the office to be seen. A lot of times you say they’re low risk. Sounds like they have the flu. Here’s what I would do. And here’s what I would watch for. And we check in tomorrow.
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Typically, we just schedule a text message for the morning to go out at 7.30 or so. So that by the time that we get into the office, the parents have already replied and told us how so-and-so is doing today. So then we can decide if we need to see them or if they’re good and tucked in and
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watching Disney plus and don’t really need anything for the rest of the day.
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Gotcha. Yeah. And then maybe I can share a little bit about my day. So. I think we’re probably like a little bit opposite ends of the spectrum because you got a robust family life. I have a lot of pets and a husband, but I don’t have kids. And so that gives me a lot more flexibility, honestly.
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And I really like not having to wake up to an alarm and just letting myself wake up when I want to wake up and working out in the morning or doing a little bit of gardening during summer or doing a few other things. And so I start work at 10. That’s usually when I start seeing patients.
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If I really need to during the busy season, I can, or like I have a packed day and then suddenly a member needs an urgent visit, I’ll add in someone a little earlier. But usually my schedule is 10 to six. I work three weekdays a week. So usually Monday, Wednesday, Thursday. And then I do work many Saturdays.
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And because my schedule is more flexible, I like increasing that accessibility for families. So they don’t have to pull their kid out of school, especially for well visits. I see kids after car accidents and do hypnosis and mind body therapy. And so it’s really nice.
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They love those Saturday appointments where they can come and they don’t have to pull their kid out of school. they also love those late afternoon the four o’clock and five o’clock appointments are really really popular because again you know they don’t have to miss school or
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they can come after school but again if i you know my my clinic partner margie she has young kids and so she structures her schedule to start around nine after she drops her kids off at school and then she’s got to be out by 2 p.m on some days and
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she makes it work and she doesn’t work weekends most of the time or You know, she works weekends only when her ex-husband has the kids and she doesn’t. So it’s very customizable. I love that about it. And if I need to take a Saturday off because there’s an event I want to go to, I can do that.
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Then in general, my families are very understanding. and you know i’m flexible enough that it’s like well i’m not in on saturday but i can stay a half hour later than usual to see you on a thursday or something like that and then i think just having that text access is really nice i think one of
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the struggles as i’m growing to be completely honest is finding spaces because sometimes i’m getting ready in the morning and i’m trying to eat breakfast and get all my stuff ready and parents are texting me and i think that’s a little bit of a struggle of like how to
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train them and how to carve out time to deal with the text messages and the emails during the day. I could probably get a little bit better at actually scheduling 30 minutes here and 30 minutes there to respond to all those messages. And that’s something that, you know,
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we have to figure out each of us for ourselves what works there. But generally I do, if I have a half hour when a patient is not there or my lunch break, I will respond to those messages. Yesterday, I had a particularly crazy busy day and I had a new medical student and we were in
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our new building and trying to figure out the workflow in our new bigger building and everything was a little hectic. And parents were just texting me. It was a Monday too, which when I tend to get more text messages, you know, there were two of them that I just responded, Hey, I’m having a really busy day.
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I’m so sorry, but I’ll get back to you later this afternoon or evening as soon as I can. And they were very understanding, but just that communication of like letting them know what’s going on, that I’m not ignoring them, that I will respond.
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I’ll get back to it. I want to give it the time and attention it needs. And I mean, if you, provide that, like if they have the trust that she responds when she’s able, and we haven’t had a lot of messages go unanswered, or we had to like, be like, Hey, did you forget about me?
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Then they know, okay, he or she will respond when they’re able to. And I’m okay waiting because this isn’t an emergency.
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Yeah. A few other things about like my day to day, I usually take an hour for new patients and for all physicals. I give myself an hour and then for follow-up visits or sick visits, usually that’s half an hour, depending on what it is. If it’s, you know, a complicated sick visit,
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I might give a little more time, but in order, as I grow in order to maximize the number of people that I can see, most follow-ups are an hour. I do the autism evaluations like you do, and that’s usually a much larger slot depending on the age of the patient.
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And sometimes I do integrative consults that are very complex, and I’ll give myself 90 minutes for that, which is nice. I’m kind of bad at scheduling lunch breaks. I sort of maybe a 30-minute break. but only because i really like having my tuesdays and fridays off and i’d rather
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squeeze what i need to into those days rather than have a structured lunch break and sometimes i have no shows and so i do that you know that’s something i’ve debated recently as i get busier maybe i should be better at structuring a lunch break that’s one of the things that you know leaving the fee-for-service world used
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to always just you know work at my desk eat lunch while i was charting i’m no longer having to do as much charting during lunch. But, you know, it comes with other challenges. I’m maybe managing emails about the business side of things or dealing with employee issues and things like that.
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So it’s still a balancing act just in a different way than it was in fee for service. But I have the flexibility. If I want to block off an hour for lunch, I can block off an hour for lunch. Like that’s completely up to me. And it’s nice to have that freedom and flexibility.
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Oh yeah. I think that I like, there’s a book, the mountain is you. And I think that in direct primary care, the mountain is you. Like there aren’t people breathing down your neck telling you have to do it this way or that way. You can be super flexible,
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but you also have to be disciplined enough to like put the time in for the things that need time because there’s nobody breathing down your neck. Like it’s very much up to you to create all those things and to create the rules and policies and the boundaries and all of that.
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And I think that’s the challenge and the blessing of direct primary care is that it’s very customizable. We’ve said it on probably every episode is that when you’ve seen one DPC practice, you’ve seen one DPC practice. And despite us taking care of the same sorts of patients and the same sorts of illnesses.
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We have totally different approaches to our schedule because we have the flexibility to do that. All of our different life circumstances allow those things and we figure out what works for us. And then we find the patients that that works for them.
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Yeah, absolutely. Yeah. One other thing I’ll mention is that I saw, I think someone posting on Facebook recently about the challenge as your DPC practice grows, the level of care that you were able to provide in the beginning to people can vary quite a bit from like, once you get busy, the level of care you can provide.
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And so kind of looking backward, I would say, be careful if you’re starting out that you don’t I don’t know, in a way, spoil families too much because then they will be disappointed or they might feel that the quality of care is going downhill if once the level of care that they
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received when you were first open is different two years later when you have 300 people on your panel. So again, like boundaries and setting clear expectations with families is really important. Have you experienced any of that, Phil?
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I think I… felt good going into it with boundaries. And so it hasn’t been a huge issue. There’s been a couple of times where I have broken those rules for a specific reason. And I also told them, guys, I’m doing this, but I won’t be able to do this next time.
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There was a family who had a brand new baby and their toddler had a scalp laceration. They texted me a picture. It was like six o’clock. They needed a staple. And I said, guys, This won’t be an option next time, but I’m just playing outside with my kids right now. Come over to my house.
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I have staples at my house and like did it, you know, they were still in their car seat. Just plop the staple in real quick. And I tell them like, this won’t always be an option. Typically you would have to go to urgent care or wait till the morning or something along those lines for this.
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But I know that you just had a baby and you don’t want to go sit in urgent care. And it’s not a huge infringement upon my time to do that. Yeah. So I think that I have boundaries, but then I will flex them, but I’ll let them know, like, this is atypical.
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Exactly.
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Or a baby had been born and like they, they got a circumcision in the hospital and then it was a bleeding a lot. And my wife was at book club. So I wasn’t inconveniencing her or putting her out to be like, I need to go help this family. So I ran to my office.
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We have kids that, you know, are old enough to babysit each other. And ran, grabbed a Surgicel, went over to their house, put a Surgicel on. Like, obviously that’s not going to be a frequent sort of flyer sort of option, but it made a huge difference to that family.
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It saved them to trip to the ER with their newborn. So there’s times where I’ll flex my boundaries a little bit more, depending on the level of inconvenience that it’s causing a cause for me and the others that I can inconvenience in my small family. year. And so, but by and large, like we do a really,
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I think a good job of onboarding patients to here’s how it works. Here’s what happens if your kid is sick at two in the morning and here’s what to expect. I’m not going to run into the office to give them a dose of Decadron at two in the
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morning because they don’t need a dose of Decadron at two in the morning. Here’s what we do for Krupa at two in the morning. And here’s what would send you to the ER. Like I don’t need to break a boundary and be like, well, yeah, they’ve got a barky cough.
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I need to go in and see them at two in the morning. No, here’s exactly what happens at two in the morning. And that allows you and keeps you from breaking those boundaries and then burning out and burning out your family because of those sorts of things.
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Yeah, I will say like the whole boundaries issues. We talk about it a lot because it’s so important. And we’ve learned something about the hard way, right?
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Totally you, you get to make the boundaries.
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Exactly. Yeah, there’s no like system around you like that’s like creating those boundaries or like, you know. Most practices, your patients don’t have your direct number, so they can’t bother you at 8 p.m. or at 2 in the morning. But here, that’s different depending on how you set it up.
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And, you know, I’ve learned some stuff the hard way. I think I’m better now about communicating to parents. Hey, if you text me, if it’s something urgent, I’ll get back to you usually within an hour. But sometimes I’m in the middle of seeing a patient and just busy. So, you know, don’t worry.
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Try calling me if it’s something really urgent and leave a message so I know like, oh, so and so just tried to reach me. But if it’s less urgent, you know, you might hear back after several hours. That’s okay. Don’t worry. I tell them I’m not going to get up in the middle of the night.
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Some pediatricians, though, you know, they say I’m 24-7. Right. especially house call DPC pediatricians, they tend to be willing to, you know, address some of those more urgent issues in the evenings or night times. But it’s completely up to you. Like, you know, just know yourself, be realistic.
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So I think sometimes it’s really hard for us to be realistic. We’ll say, oh, you know, Marina of the future will be fine doing this. But you have to ask yourself, like right now, If someone were to ask me to do this, would I be willing to do that?
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Right.
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Super realistic about what you’re willing to do and not do and be careful not to over promise parents in the beginning, especially when you’re desperate for families and you want to really sell your services and you want to show how amazing you are. I think there’s that.
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tendency to oversell and say i’m at your beck and call and like you’re gonna text me exactly you know a minute later i’ll get back to you and then you run the risk of burning yourself out and you don’t want to end up in that place that you were in
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the fee-for-service world because then what was the point you know switching over
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exactly like if you don’t put those boundaries in place, then it often does become a burden on you or a burden on your loved ones if you’re constantly doing those sorts of things. And it’s tough to say no because you can say yes. Like I can certainly run over and do a staple at 7 p.m.
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Yeah.
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And it’ll make a huge difference. And I’ll get all sorts of, you know, praise from that family for doing that. But if it’s super inconvenient to my family and it makes it puts them out, then I really need to think carefully about how am I going to say no in a way that
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feels good to me and doesn’t leave them hanging. But it’s because I haven’t promised that at 7 p.m. I’m going to go run over to their house to throw staples.
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Yeah.
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And so sometimes it works out and sometimes it doesn’t. And that’s OK. Like I don’t have to just because I did that for one family doesn’t mean I have to do it for every family every time either.
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Definitely. Yeah. And I’ve had situations where usually I wouldn’t do it, but I, I’m, you know, like a baby who was a month old and I was worried had RSV and on a Sunday evening I go in and it really depends, but I’m not going to go on a Sunday evening for ear pain that just started. Right.
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Like, because do ibuprofen, you can, you can watch away anyway. That’s the recommendation. Right. And I think I’ve done that a couple of times when there’s like stitches or an injury or like a baby that was just discharged from the hospital, had borderline serum bilirubin and needs to be followed up 24 hours later.
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Like I had my business classes all day one day and I met the family at 7 p.m. after my business classes. I was like, this is what I can do. This is what works for me. I hope that’s okay. And they were super appreciative. I said, usually I wouldn’t do this, but this is an important situation. Totally.
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and yeah when we can but again know your boundaries know your limits know how much you can realistically do and please please you know i beg every dpcp out there don’t burn yourself out you don’t want to just recreate the dysfunction of your previous life in the fee-for-service world and it’s on you to really make that
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happen because like phil said the mountain is you right
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I think that’s the biggest thing. And like, if you can set the expectations low, then it’s really easy to go above and beyond and go really notice. But if they expect the 2 a.m. croup Decadron, then… they’ll say thanks, but next time they’ll expect the same. So it’s better to set the expectations at a reasonable place.
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And then it makes it much easier to exceed those expectations.
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Yeah. Yeah. And be careful with the mental gymnastics. I think I struggled with it in the beginning of like, but I’m charging people. Sometimes like for newborns, $150 or $200 a month, like I have to go above and beyond. And actually, not really. I think like the care that we’re giving them,
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like the one hour long visit and the text messaging, that is worth it. You don’t have to go to their house at 2 a.m. to show that you’re worth that price, right?
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Totally.
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Yeah. Anyway, well, that’s all I have to share about my day-to-day schedule. Thanks for listening and we’ll catch you next time.
