You wouldn’t have become a pediatrician if you didn’t care about kids and families and go out of your way to serve them. A desire to serve on a more satisfying level may have been what drew you to starting a pediatric DPC practice in the first place. Sometimes your desire to serve leads you to do things that could lead to a whole new and different kind of burnout than you might have experienced in corporate medicine. As an experienced DPC pediatrician, I want to tell you that establishing good boundaries is the best way to have a sustainable practice that serves families for years to come while creating a life for yourself that brings you joy and satisfaction, instead of burnout and bitterness.
When I first opened my practice, I worked hard to establish a direct primary care pediatric practice in a place that was less than friendly to the idea. As a result, I did not have great boundaries because I was just so desperate for it to work. I gave more of myself than was sustainable for the long run.
In addition, I had all of these ambitions to make the world a better place for kids and families. This led me to do things that I might not have otherwise considered. For example, I was available all of the time, I drove long distances to see patients (as a home visit pediatrician), I didn’t charge enough money for what I was offering and I allowed families to dictate tedious vaccine schedules.
As my practice evolved and became more established, I pulled back on some of those things so that I could create a more sustainable life for myself and continue to grow a practice that I could love. A practice that could stand the test of time.
Boundaries are Important for Everyone
For the same reason that you teach your child the boundaries of where they can and can’t go while you are near a busy street, boundaries do the same when you are running a direct primary care pediatric practice. Establishing clear lines not only helps you to thrive as the pediatrician, but it also helps your patient families to have clear expectations of your practice and thrive as well. The thing that initially draws patient families to a direct primary care practice is often the trauma that they have experienced in the insurance based medical system that offers short visits with a rushed “provider” who may not even be a doctor. Often the root of this trauma is not getting the things that either they were promised or expected from an encounter in this system.
When you start a direct care practice where you have a direct relationship with your patient and their family, it can be easy to over deliver in a way that intrudes on your boundaries. Now, don’t get me wrong. Overdeliverly in business and in medicine is the right way to do things and also helps you to establish trust with new families. However, allowing people to run through the clearly defined boundaries around your time does not do yourself or even the patient family any good. Over time, it can cause you to react in ways that may be less than professional.
Several years into my practice, I found myself in this situation. I allowed a patient family that was new to the practice to have many more unscheduled visits than was my typical way of practicing. Over time, the mom grew to expect this level of service and I grew frustrated and upset because she was not paying nearly enough for her to take up this much of my time. It resulted in me writing a less than professional email to the entire practice explaining my boundaries and how the practice worked. After this event, I had to take a step back and learn how to overdeliver without exceeding my personal limits. It took some trial and error, but I got to a place where I felt like I was providing great care within a boundary that was comfortable for my lifestyle. This will look different for each individual doctor and DPC practice.
Firm Boundaries Give You Room to Grow
Establishing a set of boundaries around your time and your practice gives you the opportunity to grow your practice. Without boundaries, you are spending your time serving the whims of your patient parents and you don’t have time to market your practice and do the other things that are required for it to grow.
As the owner of a small medical practice, you wear many hats. When you are first starting out, you may not have any staff which means that you are doing everything yourself. You can’t spend 100% of your time on the doctoring part of the business or your revenue will never increase. In addition, your family and your personal time will suffer. You can’t allow patient families to have full access to you at all times. You need to be able to set aside time where you can work on the actual business and not just the day to day running of the business.
This is why setting certain expectations and placing boundaries around times that patients are allowed to call, text or be seen is so important. These types of boundaries can look different for each person. Here are some examples of boundaries that you can set.
- No texting after hours. Some DPC doctors don’t allow their patients to text them after hours. If the patient needs something that is urgent, they need to call.
- Turn off your phone overnight. Emergencies should be seen in the emergency room and notify me in the morning.
- Set specific days and times for certain appointments. When my practice was growing and I had a large majority of school aged kids in the practice who all needed after school appointments, I set the boundary that I would only do after school appointments on Mondays and Tuesdays. This was because these were the days that my young daughter attended an after school program. I prioritized spending the after school hours with her Wednesday through Friday and did not schedule appointments during those afternoons.
As long as patients are made aware of these boundaries in advance, most people are very understanding about the limits that you set. And if they aren’t, they are not a good fit for your practice.
On Occasion, Boundaries Can be Flexible
While you probably don’t want to make yourself available to your patient families for visits after hours, on weekends or holidays all of the time, occasionally seeing a child to care for them during these times might be acceptable to you. In one of the DPC Facebook groups, a doctor posted a story about seeing a patient on a holiday for stitches. He was able to see the child quickly, place a few stitches and everyone was back to holiday festivities in no time at all. While this is not possible if you are traveling out of town or otherwise unavailable, an occasional flexibility in your boundaries can go a long way to help a patient. In this example, this family saved time and money going to the ER for this injury.
When I was actively practicing in my peds DPC practice, I would occasionally see a patient on the way home from something on the weekends. On the way home from church was a time that I could easily see a patient for a quick sick visit because most of my patients lived close to my home and church. If it was convenient for me, I would offer this to the family. If it was not, I would offer to see the child on Monday morning. Every week looked different and each season of my practice looked different, but part of the appeal of direct primary care for both the doctor and the patient is convenience.
No Margin, No Mission
Just like you can’t run a successful practice without charging enough money for it to be sustainable, you can’t run a successful practice if you don’t have certain boundaries around your time and service. Creating a practice that you love takes some time and experimentation. Implementing good boundaries from the start should be your number one priority. As we talked about earlier, you can overdeliver your service to your patients without overstepping your boundaries. Burn out is one of the main reasons why physicians close medical practices and/or leave medicine. Don’t let yourself create a new kind of burn out that pushes you out of medicine. Take advantage of the resources that are available to you.
One of these great resources is the DPC Pediatrician podcast. Dr. Marina Capella and Dr. Phil Boucher had a great and candid conversation around this topic of Work Life Balance on the podcast in September 2024.
Dr. Andrea Wadley is a retired pediatrician who owned 127 Pediatrics from July 2018 to December 2024. She continues to have a passion to see pediatricians succeed in the direct primary care model.
