00:00.00

marinacapella

All right? We're live go ahead.

 

00:00.58

Phil Boucher

Hey, everyone welcome back to another episode of dpc pediatricians Today we are going to be talking about a very common question that I think lingers on people's minds when they are considering starting their practice growing their practice and that is the issue of. Needs of our patients and their parents sometimes people worry probably frequently worry that they're going to start this dpc practice and they're going to be inundated with really needy parents and patients if we can be honest. It is often the parents that we feel are the needy ones of the children are not always as needy. Um, there certainly is the subset of special needs children that we'll talk about too. But I think oftentimes pediatricians worry less about those kids and more about parents that are demanding. Or that have a lot of expectations or a lot of questions and concerns and so marina I want to hear from you what your thoughts or what your experience has been like with both sets of if we're we're talking about the high needs parents that have you know, typically growing and developing kids with the routine kind of illnesses and questions of of childhood. And then separately those children that have complex medical issues or are more special needs or high needs and in those regards.

 

01:22.62

marinacapella

Yeah, ah sure I'll answer both so first regarding the high needs parents. Yeah I would say yes but I have not found that I've attracted more high needs parents than I did when I was in other practice settings.

 

01:24.00

Phil Boucher

If if.

 

01:36.70

Phil Boucher

Yeah.

 

01:38.51

marinacapella

There's always just gonna be a subpopulation a certain percentage of parents that are more anxious. More worried have more questions I have noticed though now that I've been in this for two and a half years those families who were more anxious more needy had more questions just yeah know, um, needed more of my time in the beginning.

 

01:41.36

Phil Boucher

Right.

 

01:57.26

marinacapella

Over time I think they've sort of calms down because we've developed that relationship and they don't have to have that anxiety of like oh my gosh I have to remember the hundred questions I have for my pediatrician and ask everything because I don't get a chance to ask them outside of the visit and I have to remember everything now right.

 

01:59.28

Phil Boucher

No.

 

02:06.97

Phil Boucher

Totally.

 

02:12.97

Phil Boucher

Right.

 

02:16.34

marinacapella

Um, and then also just over time I Like to think I have a pretty calm demeanor when it comes to parents and there's something calming about you know them coming in you know time after time and just feeling cared for and feeling that their questions are going to be answered and that even. Sometimes question I mean because sometimes I get really complex questions and I don't have answers to everything right? I think that happens to all of us. Um, but even then they still feel cared for it and they know that they can rest assured that I'm doing everything that I can to find answers or to help their child.

 

02:35.87

Phil Boucher

Right? right.

 

02:53.27

marinacapella

And that just kind of brings you know a lot of that tension. A lot of that anxiety down over time and so I have found that those certain families that were particularly ah or parents that were particularly more needy or anxious in the beginning over time. It tends to calm down quite a bit. So um, that's ant.

 

02:57.26

Phil Boucher

Totally.

 

03:10.56

Phil Boucher

I've noticed the exact same thing for me. Um I think that it's episodic Sometimes I'll have a spell where they have a lot more questions and concerns. But on the whole I would say that.

 

03:12.60

marinacapella

Go ahead.

 

03:24.49

Phil Boucher

Are like parents are always like I'm sorry for having so many questions or being so needy and I'm always like you're not even in the top 10 Um, when it comes to to needy families when they have a period of illness or something along those lines I think we're able to help them so much more easily, especially in part because of text messaging. Um that.

 

03:31.64

marinacapella

Ah.

 

03:41.42

marinacapella

Um, yeah.

 

03:42.84

Phil Boucher

That it doesn't rise to the occasion and I also think that one of the things that we don't necessarily take into consideration or or think about in advance is it's so much easier when it is so much easier to access your pediatrician via online appointment scheduling via text message via email via. The ease of getting in to see your dpc pediatrician that it it's calming in and of itself because I as the parent know that I'm going to have time given to me when I need it rather than I'm gonna have to call I'm not to wait on hold I'm not to leave a voicemail and pray that somebody calls me back today. Like it's just totally different experience from the parent side of things that I think that in and of itself lowers the anxiety like I know somebody's going to be there for me. It's almost like triple a like well if I get a flat tire I'll just call triple a like I I already know I have that that figured out something along no long gives you that calm that comes from if something comes up.

 

04:35.90

marinacapella

Are.

 

04:41.49

Phil Boucher

I know that I'll be able to get it addressed and then kind of to your point too. Checkups are actually a lot faster because they don't hold on to all those questions because they're like grasping for every little bit of care that they can get and they come up for their four month checkup and they have a list of 72 different things to go through well when those.

 

04:44.57

marinacapella

Ah.

 

04:59.88

marinacapella

Ah.

 

05:00.47

Phil Boucher

And up at least 64 of them. They just texted or we talked about at the last visit because we had a long time to chat and I gave them extra anticipatory guidance because I knew that they would have these questions coming up. Um or they they just felt calm and easy about it and knew that ah, if. This comes up I know that I'll be able to reach out so it actually makes for faster visits I think in terms of the the parents questions and concerns because we're able to touch base on a regular basis and a lot of those kind of random questions. They just text us and we just text them back when we have time. Ah, it's often like hey this is not this is not an urgent question at all. I was just wondering this and then I can be like okay here's what you do and then it doesn't come up at the checkup because it's already off the list at that visit and so I think that those are are 2 different ways that you might not consider that actually the patients aren't all that nady and I I have we haven't got the point where we've ever said hey you're asking too many questions.

 

05:51.92

marinacapella

Ah.

 

05:56.81

Phil Boucher

Or you're over utilizing our services even for our families that I think we would recognize on the phone or when we see their text message come in that they ask more questions than the average bear that none of them are taking advantage of us none of them have.

 

06:11.74

marinacapella

Ah.

 

06:12.64

Phil Boucher

Expectations that are out of the normal for their season of life or for their Baseline anxiety and worry and if they are then we probably just need to talk to them about if they're getting the support that they need because they're probably having a lot of untreated unmanaged anxiety that's leading them there and we could say hey. We've noticed that you're calling a lot and you have a lot of these linking questions are you doing okay like how can how can we help and it's usually not. They're doing Okay, it's usually that they need somebody to tell them hey I think you could use some help and we're able to kind of help them along in that way.

 

06:41.25

marinacapella

Ah.

 

06:49.90

Phil Boucher

And make them feel heard and understood whereas if they're going to a large clinic where they're seeing 17 different providers in between all of their regular checkups. It's easy for those to get lost or they just are just looked at as like ah you know an overly anxious hypo andriac parent when really, they're just like needing.

 

07:05.60

marinacapella

Um, yeah, um, oh definitely. Yeah I definitely have had many parents open up about.

 

07:09.50

Phil Boucher

More than they're they're getting and we can be the ones to recognize that and then help them along.

 

07:18.94

marinacapella

You know as I work with their child who is starting to exhibit signs of anxiety or lip issues and the parents start to feel comfortable and they open up about you know I've struggled with this, you know my whole life or I've into therapy in the past and.

 

07:21.24

Phil Boucher

Right.

 

07:29.38

Phil Boucher

Totally.

 

07:34.15

marinacapella

Sometimes they've gotten to a better place themselves. But sometimes they admit that they still struggle and so we can be partners with them in terms of just gently nudging them to you know, take care of themselves just as much as they take care of their children because that can easily go out of balance when you have young children is like.

 

07:42.28

Phil Boucher

Yeah, yeah.

 

07:52.85

marinacapella

Prioritize the needs of your child but you don't always step back and see the bigger picture that like oh my well-being is tied to the well-being of my children and then so I need to also take time for myself and we can gently nudge that along so and to answer the second question of whether dpc.

 

07:54.89

Phil Boucher

Rape.

 

08:03.64

Phil Boucher

Probably.

 

08:11.62

marinacapella

Attracts more high needs children like children with complex medical needs or psychological needs. Um I don't I don't know that it attracts more compared to a traditional practice. Although I think it depends on how you market yourself and what kind of niche you're trying to you know, get into.

 

08:24.25

Phil Boucher

Great.

 

08:30.43

marinacapella

For me as an integrative Pediatrician I would say I probably do attract more interesting children I think they're interesting anyway because it's all of those cases with like all these complex diagnoses or like you know, unknown um causes of problems.

 

08:37.87

Phil Boucher

Um, saved.

 

08:47.84

marinacapella

And and sometimes parents come to me because they're frustrated. They say I've gone to my general pediatrician and they're just not really like taking my concern seriously I know there's something wrong and recently I had a mom bring in her almost two year old because he's been getting sick a lot I mean. His first year in daycare. Yeah, he got sick every month or 2 and she was like I know that's normal but he was getting sick like you know for two months every week being sent home with a fever and something just told her that something wasn't right? So we dig did dig deeper and are still working on that. Um.

 

09:14.84

Phil Boucher

Um.

 

09:20.99

marinacapella

But I because of that integrative Pediatric specialty I tend to attract more of those complex and interesting patients. But I actually love it in my past life in a regular practice I did not love it. That's I did not love getting those sorts of patients because I hadn't I did not have the time. Yeah.

 

09:33.50

Phil Boucher

Right? because it takes a long right? totally.

 

09:39.47

marinacapella

I did not have the time or the capacity to properly care for them and now because you know I have much longer visits and I can a lot more time as needed. Um I don't feel that I don't have the time to ask all the right questions I don't feel that I don't have the time to.

 

09:52.70

Phil Boucher

Right.

 

09:57.90

marinacapella

Um, explore things further to do some research um, educate myself about a new condition. You know that I might not be an expert in so I actually enjoy it much more than I used to I enjoy getting those interesting and complex cases because it keeps my job interesting and it keeps me learning.

 

10:03.29

Phil Boucher

Right.

 

10:15.14

Phil Boucher

Order on you.

 

10:16.62

marinacapella

And I feel like I'm able to help these kids and families who are desperately seeking help and wanting help and they have had trouble finding it in other places. So what about you? What about you? Do you attract more complex patients.

 

10:27.70

Phil Boucher

I echo I would agree I echo everything that you said I think part of it is that you have more time like I love in my past life is like okay these visits are so fast. How am I supposed to do an adh d of l in 15 minutes and now um.

 

10:36.10

marinacapella

Ah.

 

10:42.77

marinacapella

Um, yeah.

 

10:44.96

Phil Boucher

what we do what I do at every every single adt uval. Um is I bring my ipad in and we talk through things and we come up with some visual things that they do and the kid like I give my kid the kid my ipad they write down something that they're going to do and then they make check boxes and then we go you know hit print and they so they go find the printer. And print it off and then they have this thing that they take home where it's like a visual thing that they can practice just having the time to do that is really fun for me and it makes a huge difference for the families to see. It's not just about pushing pills. It's about like let's try these strategies first and then and then follow up from there. So there's just kind of 1.

 

11:21.93

marinacapella

Ah.

 

11:21.99

Phil Boucher

Example that came to my mind as you were saying like in my past life. These were really hard and challenging and now it's just like you have time and and I get to learn more. Um, you talked me into doing Autism evaluations or you kind of you didn't talk me into that but you did them and then I was like oh Marina does them I should do them too.

 

11:23.92

marinacapella

Yeah.

 

11:31.63

marinacapella

Ah.

 

11:39.41

Phil Boucher

Um, and those are some of my favorite things to do not something that you can do as a general pediatrician in a typical practice because in the 90 minutes that you're doing your ados. You could see you know, ah at least 6 or 7 patients and the the revenue lost in that 90 minutes would just wipe out anything that you could do to make up for it.

 

11:39.82

marinacapella

Ah.

 

11:42.27

marinacapella

Oh no.

 

11:59.50

Phil Boucher

Um, but they're so grateful and it's so fun for me to get to do those and that kind of speaks to our last episode about helping in the community like there's a community need for those and that's something that we're able to do now complex medical kids I think do great in the dpc model. Um.

 

11:59.89

marinacapella

Ah.

 

12:10.13

marinacapella

Ah.

 

12:16.95

Phil Boucher

Because we have the time to kind of be the quarterback that helps them with all of their different things. Um, we have the time to call and make appointments for them I mean my nurse does that I don't personally do that but but my nurse will call and set up appointments for them or play kind of quarterback to make sure things aren't getting dropped or lost.

 

12:30.80

marinacapella

Ah.

 

12:35.60

Phil Boucher

Ah, in the shuffle and so for me, that's something where I really like taking care of those families that have complex medical needs I'm thinking kids with neurological conditions are heart conditions or Gi issues kind of those are the big three in pediatrics where they're more complex and have a lot of different pieces going on.

 

12:48.95

marinacapella

Um, ah yeah, ah.

 

12:54.10

Phil Boucher

And so I love getting to take care of families that are like that and they're so grateful to have somebody that knows their child so when they go in for you know their sick visit. It's not like somebody didn't realize that they have congenital heart disease or something like that because they see 17 different.

 

13:02.00

marinacapella

Ah.

 

13:08.17

marinacapella

Yeah.

 

13:10.88

Phil Boucher

Providers at their large clinic like we all know that they have congenital heart disease or they have broncoulmonary dysplasia chronic lung disease whatever um, all these different things. We know those things about them so we don't have to like start from scratch of being like oh your kid is coughing they always cough. Yeah, they were born at twenty four weeks and like this whole history.

 

13:28.60

marinacapella

Um, yeah.

 

13:28.78

Phil Boucher

Just are able to skip that. So I think that families really appreciate that too and it's really fun for me to get to interact with them take care of them and keep up to date like you said on on what the most recent treatments and management options are because I'm not inundated with seeing 30 plus patients per day I have time to do a little.

 

13:39.10

marinacapella

Ah.

 

13:46.27

marinacapella

Um, ah yeah, ah yeah, yeah, and we can learn about things that you know that.

 

13:47.60

Phil Boucher

Googling a little up-to-dating a little bit of looking at the journals and all those sorts of things to stay on top of that and figure out what works well for them.

 

13:59.38

marinacapella

We didn't necessarily have time to learn about before I think I saw you post recently on social media about Pandas which is is sort of post streptococcal psychiatric issue that can develop but some Pediatricians believe it doesn't exist and so they just kind of brush off concerns. But.

 

14:02.62

Phil Boucher

Totally yeah ah he does right.

 

14:14.60

Phil Boucher

Right.

 

14:16.31

marinacapella

You know and it's not something that I really learned but a lot about I knew it existed ah but I didn't really know much about it. But now I feel like if a patient comes with you know some sort of complaint or concern about possible Pandas then um I can say you know what I'm going to.

 

14:20.90

Phil Boucher

Um.

 

14:33.32

Phil Boucher

Who.

 

14:33.56

marinacapella

Dig Deeper I'm going to learn about it. We're going to figure this out together right? as opposed to before when I said well go see a specialist who knows something about this because I don't have the time right? Yeah so.

 

14:41.48

Phil Boucher

Right? And that's how I was to and that like now like there isn't a specialist in Nebraska for pandas anymore. Um, and so those patients don't have anywhere to turn and so then you can say well I'm going to learn more about it like I have a book on my ipad or so right, there. Um, like learning about pandas learning about pda pathological demand avoidance. Those are things that I never had time for before and now I'm reading like 3 or 4 books about it just to learn more so that I can help those families and educate families and be like hey.

 

15:04.73

marinacapella

Yeah, ah.

 

15:14.17

Phil Boucher

Maybe it's not that you just have a bad kid. Maybe your kid is not odd like they were diagnosed by their pediatrician as maybe they have pandas or autism or pda or Rsd or all these different things that you just never took into consideration or knew before and never could have time to like pick out in a.

 

15:25.43

marinacapella

Yeah.

 

15:33.44

Phil Boucher

8 minute visit

 

15:34.50

marinacapella

Um, yeah, exactly exactly um, shoot. There's something else I was going to say and I forgot. Ah oh yeah, I was just going to share a story. Recently is I Recently had this interesting case of a teenager who had an elevated copper level. Um, and it had been tested because at her last Pediatrician She she's on the autism spectrum and Mom had been reading a book saying hey micronutrient levels can be.

 

16:00.84

Phil Boucher

Um.

 

16:03.35

Phil Boucher

You know.

 

16:04.25

marinacapella

Low or high in in this condition so she had asked for pediatrician to just check some stuff right? and so by the time she came to me she had this mysterious elevated copper level and so at first I wasn't too worried I wasn't too high I said let's recheck it in a few months and if it's still continuing to go up.

 

16:22.78

Phil Boucher

Right.

 

16:22.93

marinacapella

Then we'll dig deeper and so sure enough we rechecked it a few months later and it was going up significantly and so I had to do something and in my last life I would have hated this because I would have just been like when am I going to have time to call the specialists and coordinate care and and read and figure out what this could possibly be.

 

16:35.98

Phil Boucher

Right.

 

16:42.20

marinacapella

Um, and it can still be so tough sometimes to come up with the time but I knew I could do it and so I like read about you know what could cause it I went down the wilson's disease pathway and figured out. Ok what kind of testing do I need to do to rule out Wilson's disease because it's not something I see every day.

 

16:51.38

Phil Boucher

Right.

 

16:59.39

marinacapella

And and then I actually had time to call the toxicologist at my local academic medical center and speak to them and pick their brain about it and then I also had time to call the Pes Gi specialist at my local center and talk to them and come up with a plan and so we came up with the plan and we did further testing.

 

17:11.12

Phil Boucher

Um.

 

17:17.80

marinacapella

We were able to rule out Wilson's disease and we're just going to keep monitoring it because we were not able to figure out where this elevated copper was coming from but we also determined that it was not nearly high enough to really cause concerns at least at this point so that helped. Ah.

 

17:31.90

Phil Boucher

Gotcha oh man I was hoping that like she was she was like had a side business of like stealing copper wire and the like I thought it was goingnna be like a really cool explanation for it or when you say copper I think of Wilson's and I think of minkeky's but I think that's copper deficiency I don't remember well enough.

 

17:38.40

marinacapella

Ah I Ah, ah yeah.

 

17:47.52

marinacapella

Ah, yeah, so anyway, but you know I brushed up my knowledge about copper stuff in Wilson's disease and I was able to provide a lot of reassurance to the family because.

 

17:48.50

Phil Boucher

Um, but yeah.

 

17:55.22

Phil Boucher

Totally yeah.

 

17:57.19

marinacapella

They saw this oh. It's like oh my doctor called and talked to all these specialists they saved us from having to like spend money going to those specialists and spend time going to those specialists and so um, you know they're in a much calmer place right now than they were I also had another interesting case of ah. Ah, forty year olds who had a really elevated vitamin d level at 100 and usually we're trying to get those vitamin d levels up of course and um, that was a little bit of a mystery search I had to investigate all the supplements he was on all these other like weird homeopathic you know things he was on and learn about those and.

 

18:17.98

Phil Boucher

Um, me right.

 

18:32.67

marinacapella

The um end result was that his mom had been giving him camel's milk for a couple of months for a different reason and apparently Camel's milk is really high in vitamin d and so when she stopped giving it to him his level went back down to normal and he's fine, but it's.

 

18:38.40

Phil Boucher

Okay, okay.

 

18:50.29

Phil Boucher

Interesting. Yeah totally I think that I mean the other thing that I really love too is just the follow up that you're able to do and I think I mean.

 

18:52.40

marinacapella

I Learned all these interesting things getting these more complex. Ah and interesting cases. So.

 

19:06.38

Phil Boucher

Parents love the texting and I honestly love the texting too because it's so easy like we had a patient that had pandas and um I wanted to start them on treatment for it and I didn't want to forget about them and let them go for a month to hear how things were going so I just scheduled 2 text messages to go out. How's he doing and then. Set that for next Monday and then for the following Monday how's he doing so that we could check in on those things and even just like another patient kind of similar just checking in over a text message hey I thought of your daughter today when I was listening to a podcast house things going and getting to hear back and just like.

 

19:30.79

marinacapella

Ah.

 

19:44.87

Phil Boucher

Those little touch points um are really neat for me because otherwise like if you're seeing 30 patients a day you're just too busy to do all of those little tiny followups that can make a huge difference for the families but also for my learning too of like oh we did this and things improved. Oh we did this things didn't really improve I'm able to like shift my thoughts and shift. My.

 

19:54.29

marinacapella

Ah.

 

20:04.52

Phil Boucher

Um, treatment plans based on the things that I hear and learn from other patients that you would just miss out on if there's the whole riggamarole of can you call and get an update on so and so and then it has to turn into a note and it has to get to me then I have to read it and do all these things like there just were so many steps for getting a followup that it was almost not worth it.

 

20:04.86

marinacapella

Ah.

 

20:23.48

Phil Boucher

And now it can be just like a quick text message of hey just wanted to check in and see how we're doing that sort of thing is just totally different in the Dpc world.

 

20:31.70

marinacapella

Oh absolutely. Absolutely yeah, so in summary I Guess when it comes to both high needs parents and high needs children. Um I would say.

 

20:33.95

Phil Boucher

For.

 

20:42.87

marinacapella

We do attract them but I don't think that it's at a much higher level than it was before but there's so much more satisfaction in being able to have the time and and give the families the attention that they deserve to help them feel better.

 

20:55.71

Phil Boucher

Yes, you'll enjoy those families so much more and you'll get to see when you've made a difference because they don't just kind of like stop bothering you. It's because you've helped them that their anxiety and their needs are met.

 

21:11.94

marinacapella

Um, absolutely yeah, well thanks for joining us and have a wonderful week.