Listen to the Podcast here: Delegation and Avoiding Burnout at Scale
Summary: This podcast episode centers on the challenges direct primary care (DPC) pediatricians face around delegation and burnout as their practices scale, and provides practical advice and personal stories addressing these issues.​
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, welcome back to the DPC Pediatricians Podcast. Today we are talking about one of the biggest issues that practices face. This is something that we heard frequently at the summit, which was a resounding success in my opinion.
And numerically, like I was shocked at how many people showed up every single day. And all of the conversations that were had in the chat and at the social on Marina’s birthday, all of those things. One of the comments that came up frequently, and this applies both to those that are starting out, those that are growing,
those that are a mature, busy practice, is… delegation and burnout as you scale. And I think these are two big issues that practices often face because you’re like, I hate seeing five patients per hour. I want out of this system. I hate being told what to do.
I’m gonna start my own DPC practice and I have a lot fewer patients, but… I am then spending hours and hours per day on the clicks and the forms and the filing and the QuickBooks and all of the different things. Like I’ve moved from being running from room to room to running from window to
window on my computer and just feeling like I never catch up because of that. And I want to hear Marina, what your experience has been like as you started, as you moved over and as you’ve grown, how has that gone? Like when have been the times first and foremost that it felt like, okay, this is, I’m,
I’m patient care wise. I’m in a good place, but administrative business owner side, I’m not.
Yeah. Well, I think like most DPC pediatricians, I started out solo. It was just me. I was the one taking the phone calls. I was the one managing the website. I was the one cleaning my rooms and bathrooms and stocking things.
I was the one trying to draw blood on patients when I felt like I had a chance of doing it. Yeah. I was the one doing all the backend business administration. I was the one rooming patients, checking vitals, doing all the charting, vaccine charting. So it’s normal because of the model.
It’s totally normal to start out that way. I know for you, you started out with employees, but that I think is a bit of an outlier. Most of us do start out just solo because we want to be very lean. We want to be responsible with our limited startup funds.
We want to wait until we actually have some income before we start spending more money on help. And that’s definitely how I started. And about nine months in, maybe nine to 12 months in, is when I hired someone part-time initially to do the kind of front desk
responsibilities because I started getting more phone calls and there was more paperwork when I started doing immigration medical exams. Yeah. All of these things were happening. And I was like, I don’t like scanning things and faxing things, uploading things to a patient’s chart.
This is not a good use of my time and my level of training and expertise. So how about I hire someone? to offload some of those things that I don’t particularly like doing. And as my time started to feel more scarce and more scarce, that’s when hiring even more employees became important.
Now, most DPC pediatricians are not going to be hiring a big staff. Most people are going to be hiring one virtual assistant for something like 20 hours a week, 10 to 20, depending how big you are. or maybe one person who is a medical assistant who also doubles with some administrative duties. It’s really up to you.
I think a few of us are going to want to get bigger and therefore have multiple employees. But I think you have to ask yourself, what don’t I like doing? And all of those little administrative tasks, is it worth my time, right?
When you could be spending more time with your kids, when you could be spending more time on the patient care side and doing the things that you truly enjoy, at what point can you start to delegate more responsibilities? And I think some of the difficulty that we encounter in delegation comes from some
of the programming that we’ve inherited from the many years of medical education and training. What do you think we kind of come away from that training with that maybe is not so healthy when it comes to learning to delegate?
I mean, I think everybody remembers going on rounds and when you’re in residency and the attending is pimping the nurse on why was this medicine given at 447 and not five o’clock like I ordered? Or why did this lab not get drawn until seven when I ordered it at six? And we get this…
feeling that everybody else makes mistakes. Nobody’s going to do it just right enough. And if I want to make sure my patient gets their x-ray done on time, I am the resident that’s going to push them down to radiology. And we’re like bread for everybody else makes mistakes.
And I can’t trust anyone else to get it right perfectly.
Mm-hmm.
And that’s also part of the, you can’t get a 97%. Why didn’t you get a hundred percent on this test? And how did you miss that? And there’s all these little things that you’re just, there’s the, you keep getting the gold stars because you keep doing everything perfect.
And to suggest that something be done less than perfect or to trust somebody else to do it, maybe perfect, but also maybe just well enough is really hard for perfectionist pediatrician people to do. And so, yeah, this form could get filed. It might get filed tomorrow and not today. No big deal.
They might do the windows on Tuesdays and sweep the floor on Thursdays, which I wouldn’t do if I was in charge, but I also don’t give that much of a care to it of the order of operations of all of those sorts of things. it’s hard to delegate and to trust.
And it takes a lot of practice of delegating. Like it’s a skill that you have to learn and then practice, especially if you come from the perfectionist background that almost all physicians come from is it’s got to be perfect and it’s got to be 100%. And so I think that’s what makes it hard
to delegate especially when you’re starting off and aren’t sure if it’s going to work out and maybe you’ve delegated in the past and somebody lets you down because of course you’re delegating to other humans who are going to let you down from time
to time and then it’s well i can’t trust somebody else versus i can trust them i need to give them better instructions
yeah i agree and i think the field of medicine tends to attract people who are on the perfectionistic type a personality end of things and that in many ways it’s our strength yeah in many ways that’s what got us through our medical education and our
training but when it comes to being a physician entrepreneur we need to be able to embrace new abilities new skills new ways of doing things because we cannot be everything at every moment for everyone, right? And I think this is a really important point for me,
that if we go into DPC without checking some of our baggage at the door and examining it and figuring out, okay, what is healthy to bring with me into this new journey? And what should I leave and abandon at the door? We risk just falling into a new… setting of burnout.
Like we can recreate the same burnout that we experienced in our past work lives, just in the world of DPC. And I do see posts in our Facebook groups, and sometimes a little more among women, but I see both men and women experiencing this of I’m a few years into DPC, and I’m feeling burned out.
And some of us have a little bit of delusional thinking in the beginning, thinking DPC is a totally different ballgame. And it is in many ways. It’s going to completely solve all my problems and cure all my burnout. I’ll never have difficulties again. Well, it’s not exactly that easy, right?
You really have to create what you create intentionally, carefully, thoughtfully in order to prevent some of the problems that you have maybe tried to escape in the past.
Right. Like I think most people are like the grass is greener on the other side of the street. And then they move over there and realize that, okay, the grass is greener because they’re fertilizing it and they’re watering that. And then they’re like doing the things that they need to do. Yes, it is.
But if you just jump into it and you say, well, I can just do everything myself and I don’t need any help that works for the first 50 patients. And then when you get to a hundred patients and you’re refilling prescriptions and filling out forms, and demand, demand, demand, you’re like, jeez,
I really didn’t realize all the stuff that I wasn’t doing before that now I don’t have anybody to outsource to. And so then you have to figure out what to do from there.
Yeah, exactly. And I will say that there are very many different and diverse examples in the DPC community of how to do it. And each of us is going to have different things that we like doing, different things that we hate doing, a different set of personality traits, characteristics.
And so we’re not saying that you have to do it a particular way. We’re just saying that you have to really examine what are the things that you like doing and want to keep doing, want to be spending your time doing, right? Versus the things that you don’t like doing and don’t want to spend your time doing
so much and really examine, okay, when is the right time to start asking for help? That could come in many forms. That could come in the form of your teenager who wants some extra cash and wants to volunteer doing some scut work for you in the clinic.
That could come in the form of a local high school senior or college pre-med who needs some time and you can hire them as an assistant in the clinic, in person or virtually. Although I would say with younger people, probably in person is a little better to begin with because there’s more oversight, right? Yeah.
And then it could come in the form of a virtual assistant. There are many companies out there, including, I think, Cool Blue VA, who has been at our mastermind as a sponsor, who basically has VAs for hire. It could come in the form of an in-person nurse or medical assistant.
In my case, I eventually grew way more than I anticipated. Now I have an office manager who two front desk assistants and two medical assistants. And it’s sort of shared staff because of the way I have two other DPC pediatricians that share the office. And so we kind of share that employee labor to some degree,
but I act as the official employer because sharing employees between people gets really complicated from a payroll perspective, but you don’t have to grow to that degree. You just have to figure out what are my needs? What do I want to keep doing? And what would I be happier offloading?
Yeah, I think the way that I, when I’ve talked with other physicians about this and for myself, like what must I do? I have to take care of the patients. Like I have the training and expertise and license to do that. What other must I do? I have to chart,
although I kind of outsource that to an AI scribe a lot of times, so I don’t have to do that. I have to send in the prescriptions myself that is just kind of under the blanket of medical care. And then I have to oversee the business and make sure like the buck stops with me
as the business owner at the end of the day. a lot of the other stuff you have to decide, do I like doing this? And is it worth my time? And if I like doing it, then I keep doing it until I don’t like doing it.
And if it’s something that is not worth my time, how much time is it worth to recover from that? And then who can I find that I can trust and train that it’s worth my time, my money to offload that to them? And then how can I make sure that they do that well?
The thing that I love now about the ease of outsourcing is the digital age. It’s not that you have to have them comb through the charts and all those sorts of things. You’re not like going to the filing cabinet and that you can record a screen share
of here’s how I put these new faxes that come in into the correct chart. I’m going to go through and I’m going to do a dozen examples because I do a dozen examples every day, I’m just going to turn on my screen share. The one that I use is Loom, L-O-O-M, which is free to record.
Here’s how I file these into the correct chart and label them and put them in just so, just the way that I like it. And then you do that. And then you say, okay, hopefully that makes sense. You’ll run into things that I didn’t cover here. Do you now loom as you do the next 50 charts?
And then I’ll look at that. Or if there’s a hiccup or something like that, just share with me what you’re facing. And then we can go back and forth there. I love like being able to do it asynchronously and have a record of it. So something like there’s one called scribed, I think is what it’s called,
but it basically does a click by click of like you click here and then you click here. It’s, it’s watching you. And you can create a standard operating procedure for scheduling that next appointment or filing that thing in the inbox or filling out and faxing the referral or whatever it might be. You can do all that.
So you create a library that then when people have questions, they say, oh, this is how Dr. Capella likes it done. Watch this video and then you’ll know and understand. And these techniques of… people that you’re finding to work for you are super savvy when it comes to tech and will get it way faster than you did.
And so it’s really easy then to have a library of ways that you can outsource.
Absolutely. I echo the Loom idea. I learned about it about, I don’t know, a year or two ago, and I’ve started using it. And it’s really great, especially if you’re hiring a VA who doesn’t live in your area. The ability, maybe their nighttime is your daytime or whatever. I know a lot of VAs in the Philippines are…
the ASU people utilize. So you can just record a video and teach them, hey, this is how I do it. This is how you create a patient chart. This is how you schedule and plan. This is how you upload patient records. This is how you send a patient who just continued their membership, their records, right?
All of that stuff, really nice tool. I think you can get the free version that gives you up to five minute videos free. And I think it’s only $20 a month if you want to get the paid version. It’s pretty good. So I use that a lot.
I’m trying to think of some examples of things that I offloaded. As it got busier, I used to handwrite birthday cards and mail them for all my patients. And that was really nice. Atlas has a little alert system that tells you when it’s someone’s birthday.
And just about six months ago, I was like, I’m not keeping up with this. I have too much on my plate. And so I hired someone who I knew who was actually the mother of one of my patients to send those for me.
And so I just send her via Amazon and UPS, like the stamps and the cards. And she does that for me. That way, there’s still that extra touch that I like having in my clinic. But I trained her on how to, how to do that. And, and she was happy to do it. So I just read,
I just read Harry Potter too, for, I don’t know which time I read it, but Gilderoy Lockhart on there has Harry signing his card doing autographs because he has so much fan mail. He can’t keep up with it. So that’s Harry’s detention is signing cards. So I had that Dr. Capella.
Yeah. And other examples, actually, my clinic partner and friend, who shares the building with me, she was falling really behind on some of her notes. And there was a med student who had rotated with us and done a rotation many months ago. And she had reached out to me saying, hey, I could really use some extra cash.
Do you have… anything that I could do around your office or virtually. And so Margie said, Hey, you could really help me. And you have the skillset because you’re a fourth year medical student. Now you can help me catch up on all of these notes. Right. And that ended up working beautifully.
She was able to offload something that it was becoming like the pile of work was becoming so large that it was easy to just get What’s it called? Paralysis at the thought of needing to do it, right? And I think all of us can experience that if something really builds up to a point
where it just seems insurmountable. Okay, if you’re starting to get that feeling, you have to hire help. Please help yourself and hire help, right? I think that’s a really good sign that it’s time.
And I think there’s a lot of different avenues where, especially as a business owner, you can find things that people can do for you. Even if you’re like, well, I only need like two hours per week at this point. Well, maybe they could do some,
maybe you could think up some other tasks for them to do to really fill it out so that, hey, when you catch up with this, I want you to then focus on this. And it might be doing some of your marketing, like your in-person like marketing, reaching out to local speech therapists or occupational therapists or physical
therapists and like trying to bridge those connections. There’s lots of things if you sit and think about it that you’re not doing that then you could say, well, if I had extra time, I would do this. It really probably doesn’t need to be me that does this.
But they can work on my behalf to get those things done. So I feel like that’s another place where people will often say, yeah, I just need to, I need a VA, but I only need them to do this. And I don’t always have the work for them. Well,
I bet if you sat with it for a little bit or asked in the Facebook groups or something along those lines, what other things could I do if I had somebody to help me? And you might even use them to help with some of your own personal scheduling of appointments or things along those lines.
And every business that has somebody that has the training and the income level of a physician, all of those people have executive assistants that do… the executive assistant in work, which sometimes is the documents, but it’s also sometimes like booking the flights or booking the massage or whatever it might be that you’re doing.
Like there’s people that you can pay to do those things for you. And especially if it’s a business expense and they’re also doing those other things. Like, I mean, that’s a great way to make your life better while focusing in on the most important things of patient care, taking care of your family, taking care of yourself.
all those things that are actually very limited time that you have to focus on those.
Yeah, absolutely. Yeah. And I’ll add just maybe one more thing, one little warning that often when it comes to enlisting help and training someone to do the things that you need help with, there is a bit of a painful period before it gets better because sometimes it’s
like you’re still having to do the thing and you’re having to train someone to do the thing. And you’re having to tolerate some mistakes because there’s no perfect person on earth who’s not going to make any mistakes. So just a little bit of a warning, because this has happened literally with every new hire,
with every person that I’ve had to train in anything. There’s a little snafu with the newsletter they sent out, a typo or a mistake, or they scheduled someone wrong and I ended up double booked for something. Yeah. They whatever it is, there are going to be some mistakes since you have to prepare yourself psychologically to be like,
OK, it’s going to be harder before it gets easier. But once it gets easier and they learn, it’s going to be a lot better. Right. So as long as you have some tolerance, if you’re willing to kind of take on that initial responsibility and extra work of training them after you get through that hump,
it’s going to be a lot better.
So important. And I think that I try and there’s a book, there’s lots of books in the business world about delegation and like extreme ownership, where if my person that I have entrusted to do this thing makes a mistake persistently, it’s either that they’re malicious, which I don’t think I would hire somebody that was intentionally malicious,
or I did not explain it to them well enough or or we didn’t have a good enough process in place. And so I’m going to take ownership of that. And if the scheduling is in error, then I’ll text them and say, Hey, I totally goofed up. My scheduling availability doesn’t work.
And I’m so sorry, let’s make this work or you, you own it. And so when you do that one, it makes it feel a lot less like this person is out to get me, or they just don’t care, or they just don’t do a good job. Um,
we have i have essentially the exact same team as when i started four years ago because we focus on okay this is how it went last time this is how it could be 15 better for next time if we can figure out this and where is the issue here and it’s
usually right here but um marina’s laughing because she knows she’s we work together marina and i have interacted enough to know that it’s usually right here where the the actual issue lies and when i can be like hey going forward i think this would
work better here’s the system that we’re going to put in place things go so much smoother but it does take that uncomfortableness and the frustrations and the working through like it’s it’s like the toyota factory line i’m sure that the first time that the car comes out of the factory,
they got the doors on the wrong side or one of the wheels isn’t tight enough or something along those lines. But then we go back and we see, okay, here’s where the issue was. And this robot needed to just tighten it a quarter degree more.
And now we have this beautiful Toyota Camry that rolls off and they roll off perfect every single time because we took the time to figure out all those little tweaks along the ways that made it better.
Absolutely. Yeah. So we both encourage you, if you’re getting to that point where you feel like you’re getting too busy, you’re feeling like the days are longer, you’re feeling overwhelmed, you’re feeling like maybe you’re having to sacrifice time with your family or time for yourself or your sleep, please, please consider delegation.
I would say, do it even before you start to feel overwhelmed. If you see it on the horizon, if you see that your panel is growing and that the tasks on your plate are going to get proportionally larger with that growth anticipated and give yourself kind of a timeline of in three months,
I think I’m going to be there financially and just logistically, I’m going to need someone. Right. And don’t be afraid to enlist help. Can I guarantee that the first person you hire is going to be a perfect fit? I cannot. Yeah. But I do think it’s worth searching and trying to find a good fit to enlist help,
to take some things off your plate, to be able to enjoy your work and personal life to the degree that you deserve to enjoy it.
Love it. Amen. Yeah.
All right. Well, thank you everyone for listening and we will catch you next time.
