Concierge Family Medicine with Dr. Scott Setzer

And who was your mentor when you became a concierge doctor? Just, you know, maybe Sarah.

Yeah, it seems like that shifted a little bit. Generations md. My name is Stephanie, and I'm joined here by my colleague, Dr. Sarah Davis, who's also my mother. And today we have a very special guest.

This is one of my good buddies from residency, who is a family medicine doctor in Pennsylvania, and his name is William Scott Setzer. So welcome, Scott, to the pod.

Thank you. I'm so happy to be here. I appreciate the invite.

So do you want to tell us a little bit about how you guys know each other and kind of your background of how you got to that point?

I can take that one. So we both. Sarah and I both did residency at University of Florida in Gainesville, Florid. And I was one year ahead of Sarah. And so we. When you're one year apart in residency, many people know you work closely with residents that are. That are. That are in the same kind of class phase as you are. So we were just one year apart. So we. We practiced together alongside each other a lot in the hospital and in the clinic. And I got to know Sarah really well, and I was. I was very fortunate that I got to be chief resident my last year of residency, and I was super excited when Sarah got to be chief resident after me. So after we left residency. So that was sort of a great bonded connection that we had, and I couldn't have been happier when she was elected.

He was kind of my mentor, or I think you like to think you were my mentor.

Oh, I was your mentor. No, it was. It was very collegial, and we definitely learned from each other, and it was a really good program. I look back at Florida as it was super high volume, and we got to see a lot of people that had a lot of social as well as medical issues. And it really taught us a lot about listening, listening to the patients and really trying to speak to patients in a way that was meaningful to them. So because we get talking, doctor talk, and you can get so far ahead, and you start to learn to recognize that kind of going. That look in the patient's eyes when they're. When you're. You're getting past what they're. But their usual way of speaking is like, they don't talk medical talk all the time. So that was really rewarding about that program.

Our residency program was also unique because we were at. We were right next to this tertiary care institution, but we were the only residents in our hospital. We were at a community hospital. And so as family medicine, we were the only residents there working with doctors in private practice. And so we really got to be on the front lines of seeing all kinds of. Of pathology or whatever else it was. A patient's come through the er. We didn't have to compete with other residents and other specialties fellows, you know, all that kind of thing that you have in a tertiary care center. Because when you're like that, when your family practice, a lot of times you get kind of squeezed out, I think, in some of those institutions. So it was great. We got to do that in our own hospital. But then we still got to rotate over at the University Hospital for things like pediatrics to see stuff that was sent from all over the state to that institution. So I think it really was a unique. A unique program. I assume it's still like that today. I don't know.

Yeah, I haven't been in touch with as many people recently. For a while I kept in touch with some of our friends, but, you know, it's like life gets busy, right?

Yeah, yeah. Well, back up a little bit because I couldn't remember. I remember you went to uva, but I didn't remember if that was for college or med school or both, or. Tell us a little bit more about your path and how you chose family medicine.

Sure, sure. So, yes, I was at University of Virginia for both undergraduate and medical school and went to Florida for residency training. So. And I'm from Virginia originally. I kind of decided. I'm not from a family of doctors, I'm from a family of teachers. But I kind of decided around seventh grade that I was interested in medicine. And it was kind of, for me, the perfect fusion between super interested in the sciences and also liking to talk, interested in people. So I always consider myself the people person. So I enjoy relationships with people. And just the service aspect of it was attractive to me as well. And plus, and, you know, no apologies, I wanted to make a good living. I wanted to, you know, have financial security. So the field seemed to promise all that for me at the time. And it's. It's done what I've done. I've been very, very happy. Like sometimes, you know, even when, you know, like, when medicine, it can be a bummer sometimes, there is a lot of things about it that are really stressful. But at the end of the day, my wife also is a doctor, and we can't think of what else we would have done, you know, so it's like, I don't ever feel like I regret my decision to be a doctor. And there are, there are moments where you, you know, if you're, if you're with someone when they're dying or you're with someone when you tell them they're going to die, that's some of the hardest things that, that you have to do, but it's also some of the most rewarding. You grow as a person every time you do that. Like, you get a real, a really strong feeling when, when you have to have those conversations.

Yeah, 100%. I want to talk a little bit about, like your choice of family medicine. We want to talk about that a bit. I think people bag on family medicine a lot, so we kind of want to talk, talk about just like choosing family medicine and then how that has shifted throughout your career.

Sure, I can bag on family medicine too. So, yeah, there's, there's definitely pluses and minuses. When I went through my training, the reason that family practice appealed to me most was because the, the, you get to see what happens. You can follow up with people over time and you get to know how the story unfolds. So I was really attracted to critical care. I was really attracted to obstetrics. But it's like that's sort of this finite period of interaction and then things go away and you don't really get to know. And I loved high acuity care, urgent care, critical care, but emergency room, I loved as well. And Sarah, remembering from residency, we had the opportunity also to moonlight in the emergency room overnight. And that was a great. And get paid for those shifts. That was above and beyond what we did for residency training. And that was all great experience and I loved it. But even at my darkest moments of family practice where I thought, wow, this is not what I thought it was going to be, I still came back to, I wanted to know the relate. I wanted to have the relationships and I want to follow people over time and know how they do so. And Sarah mentioned, you know, she started this concierge practice in Dallas. I also have a concierge practice here in Pennsylvania. And before I made that shift, I was in kind of the bind of I enjoy the work that I do, but I really have a, I really struggle with administrative, and not even administrative, but sort of the clutter part of the work. Like when you have to, you have to document 25 to 35 patients a day and they're really complex appointments. You don't really feel like you can do that during the time that they're there and you have to do it later. So it became grueling. But. And so I briefly considered, should I get out of this and do urgent care or hospitalist work? And again, I just. Family practice always appealed to me the most because you can do a little of everything and you get to know what happens. You get to know people and their families so you can be the doc for everybody in the family, which is, is really one of the fun parts.

And who was your mentor when you became a concierge doctor? Just, you know, maybe Sarah.

Yeah, it seems like that shifted a little bit. We had to switch a row. Yeah.

So she was one of the angel people who I had to talk that, you know, because it's a big leap. It's scary, you know, you build it, but they won't necessarily come, you know, so you have to put out all this time and planning and, you know, stress and emotional stress as well as true financial and mental stress. And you don't know necessarily if it's going to be fruitful. But Sarah was one of the, you know, my great mentors then. So if I was her mentor before, she certainly returned the favor.

Yeah, Well, I remember just saying, you know, you can do this. You don't need help from, you know, anybody else like you. You have the skills, have the personality. You, you know, you, if they, if you build it, they will come. And, you know, I think that's all you needed to hear.

Those were great words back in. That was, for me, it was 2010, I launched in 2011, so it was 2000, late 2009, early 2010. And I was thinking that I wanted to make a change. And you know, there are still, I still have really good friends who practice family medicine in the traditional model and more power to them and, and I think many of them are fulfilled and doing a great job. I couldn't feel like I could do it the way I wanted to with the way the model was currently set up because it's much too volume driven. And maybe you notice I like to talk. So. So it's, you know, it's hard to compress depression, coronary disease, diabetes and toenail fungus into a 50 minute appointment.

Well, I think that, I mean, we all understand concierge medicine and we touch on it a little bit on this podcast. But can you talk a little bit about like, specifically for our viewers who don't know like what that looks like, switching from a traditional practice to a concierge practice?

Sure. So in traditional family medicine. So I think, and the data at the time, and I think it's still pretty Similar was each family doc should be home to about 22,000 to 2500 patients that would call themselves their own. Some places it may be a little higher, in some cases it's a little lower. So that ends up being, you're needing to see, you know, 22 to, to 30 patients per day to take care of all those patients. So, so in the, in the traditional model, you're dependent on what insurance pays you for those services. So in my opinion, way too much of your time is dedicated toward documenting and billing and coding such that you can get paid for those services. And it's a, I understand that system and I'm, I'm not going to completely fault it, but it, it felt like way too much of my time was devoted for stuff that I wasn't trained to do or that I wanted to do or that I was interested in doing. It was administrative and billing. You know, it's like I don't want to be the best biller that family practice has ever known. So in concierge medicine, you step away from, there's different models, but the model I employ and the model your mom employs, we step away from the insurance model entirely and say we're not going to accept payment from insurance. We're taking a retainer fee, essentially a once yearly fee from our patients directly and then we're your doc. So what that means is I can have a much smaller panel of patients. My panel was capped at 300, so 300 as opposed to 2,500 or some cases, 3,000. So a tenth or a little more than a tenth of what I had before. And I can spend my average appointment time is an hour. So. And then I'm also not tethered to this model where I have to try to make sure I'm documenting this, that or the other so I can get this level of service so I can bill insurance for this much. So there is no concern about that. I write notes so that I know or the next person who reviews my notes understands my thought process and my patients thought processes that were going on in that appointment. So it becomes a much more gratifying experience for me and hopefully for my patients.

Once and once in a great while I feel like, oh gosh, you know, I'm only taking care of a very small number of people and there is a shortage of primary care doctors. And I feel bad about that a little bit, but I also feel like, well, I'm providing really excellent care to the people that I'm taking care of. And so I feel like well, that sort of justifies taking, like, not very good care of more people.

I have that pang sometimes, too, about, like, should I be contributing more to taking care of more patient lives? But two. Two aspects of that. One is like, I was losing that ability anyway. So it felt very. For. For me, like, not knocking people who can do it and do it effectively. But for me, I couldn't do it what I considered efficiently and effectively to the point where I could sleep well at night with those time constraints. So, like, it was. I. When I left my other practice, it was really emotional. And I had to say I knew I was having to say goodbye to people that I'd spent 10 years building relationships with, which was not easy, but my reconciliation was. I was already losing the ability to have those relationships. So I was not the best doctor I could be in that model. And the other caveat to that, Sarah, to assuage your guilt, is doing things like podcasts to talk about concierge medicine and grow the model, because I think it is a super effective model, and it's not. I think it gets the model of. It's the rich people's doctor. And I have patients of all kinds of different socioeconomic backgrounds. So I like to say I'm cheaper than Starbucks and Verizon, so.

Right, right. Yeah. I saw some article that was basically, you know, bagging on concierge models, and it was saying, you know, oh, yeah, there's already the shortage and blah, blah. And, you know, and my answer to that was, huh, it's almost like we're worth it, that people really want to pay us and we actually are doing good for our patients. And so if patients are willing to pay for that, insurance companies or whatever else is out there, maybe you should look at this and say, well, primary care is a worthwhile thing. Maybe we should invest more in it and actually pay the doctors, you know, what they deserve and that, you know, maybe that could actually be successful rather than trying to keep, you know, cutting down reimbursement and all that. I also think that I save the insurance companies tons of money, like in the amount of times where a Medicare patient, for example, comes in. And in a traditional practice, they would just be like, oh, you got to go to the hospital. You know, that's what. There's no way we can manage this as an outpatient. Well, I've got the time and the energy, and I can manage it as an outpatient. And if you save, you save a couple of admissions a year. You've already saved the insurance companies. So much money. So it'd be nice if that money got put back into primary care, but I don't know, it's not the way it works.

And also the, the forgotten model for home visits. So it's not like I'm doing home visits every day or even every week, but last week, you know, I had a virtual setup and I'm like, hey, you know what? Like, you both are going to be over there. It was a patient of mine that was in a, was in a temporary rehab that may end up being a longer term situation. But like, hey, what if I just meet you over there? You know? And that's just the face to face. It's just feels so good and you get so much more of a feel for the dynamic that's going on between the families, the staff they're interacting with. And you can look people in the eye and it just is very, very rewarding, you know. And you, like in the old model, I mean, right, Sarah? Like in the old model would be like, if someone needed a home visit, you'd be like, like, I gotta do that at 8 o' clock at night and I'm not gonna get to see my kids go to bed that night. You know, it's like there's, there's just no, practically, there's no way to do that. And you wouldn't even, you can bill for it, but then you have to document. And the other point that I wanted to throw in about the concierge medicine model, it's not just like knowing as the doctor how to bill or code this encounter so that you get paid, but you also must employ an army of billing personnel to submit those claims. So it dilutes the money that you're getting from insurance companies because you have to support the insurance company with the money that they're giving you, which sometimes doesn't set well. And no one becomes a family doctor because they, they want to be the most lucrative doctor or the most, make the most money of any doctor. So it's not a high, a high money making field. But if you take that already comparatively lower bar relative to other, you know, specialties or subspecialties, and you say, okay, just to stay at that relatively lower bar, you got to see more, you got to see them faster. And at the time I left, there was this, there was this big push towards something called a patient centered medical home. Do they even talk about that anymore?

You know, I'm so out of that stuff. I don't know.

No. Stephanie, have you heard the term maybe you Wouldn't at your level. So patients that are in medical home was. I mean, I'm not going to do it justice. But to me, what I heard every time that came around was, don't teach your patients, don't talk to your patients. You're filing patients and sending them to other people to do the talking and the teaching and empathizing with them. So it's basically you're almost a glorified scribe, which really robbed the me of why I did this. You know, I. I want to know the people, I want to know the family. I want to talk to them, I want to get in their head. I want to make a difference. And if you, if you're not even doing that part, like, why am I here? Right. So. And not. And there's plenty of people who do it, do it beautifully. But for me and my personality, I was not able to do it the way I wanted to.

Yeah. Kind of outside of the actual logistics of having a concierge practice, how do you feel like your life outside of the office has shifted. Shifted from going from a traditional practice to a concierge practice?

It went from not having one to having one. Look, and that's hyperbole, but it's, it's close to the truth. So my kids were young when I made the switch. And it was. They went to bed by 7:30. And so the rush was I needed to get home before my kids went to bed at 7:30 so I could see them before they went to bed. And that, you know, patient patient hours. The last patient was scheduled at 4:45. So I'd literally be sitting there trying to do documentation until then. Now, people could argue that maybe I was inefficient. Surely that's part of it. But I wasn't the only one who's there after hours doing notes or taking charts home. In the days before electronic health records. You can't imagine that. Stephanie, we had.

No, definitely cannot. We don't even have textbooks here. So I don't even know what's paper.

What'S a pencil.

So in textbooks really for you, are all online textbooks or notes that are online, right?

Yeah, 100. Just like videos and stuff online.

Yeah.

Don't have any textbooks.

Do you, like at your stage of training, it's. People probably necessarily aren't talking about what they want to do. Or maybe they are. I mean, have. Do people bring it up or like, are people already saying, oh, I'm definitely going to go for ENT or I have an interest in family medicine or I Like obstetrics or people already segregating themselves that way.

Yeah, 100%. I, like, made this video at the beginning of the year of all this. Like, every student in my class saying, like, what specialty that they want to go into. Some people don't have any idea, but a lot of people are like, yes, I want to do ent. I want to do orthopedics. I think one other person in my class said that they wanted to do family medicine.

Wow.

Yeah.

And so. And that's speaking to my point. I've led you down a road deliberately. So if concierge medicine is promoted as a more viable alternative for family medicine, then I think it's a beautiful, beautiful life to be able to have the privilege of doing this, but making it a. More. More rewarding for the patients and for the doctor. So there's less bitterness or resentment about the time you're not with your family, because the field requires you spend a lot of time from your family and also make it. Make it realistically reimbursed for your efforts. So, like, it's not, again, we're not going out to make, you know, super bank, but it's. It's nice to be. To not have to spend a lot of money on billing or chasing stuff that is nothing else trained to do. You know, it's like, I don't want to be an expert biller. Right. Never did.

Well, yeah. And I think it's kind of frustrating because a lot of what I hear is stigma about concierge medicine and saying, like, just kind of doing it for the money or whatever, like that sort of rhetoric around it. When I'm talking to my classmates who. The conversation is, oh, I want to go into orthopedic surgery because they're making so much more money than this other thing that I might also be good at. But so it's kind of just frustrating when I hear those conversations, but then suddenly, like, you're a sinner for wanting to do, like, a practice like concierge or medicine.

Well, so much of that, I feel like, comes from, you know, the way that reimbursement has been, is that you get paid for doing things you don't get paid for thinking and hearing. And so, you know, you. Somebody breaks their bone and you do an operation and fix it, well, that's worth something. You know, people want to pay for that. But a patient just coming in and talking about their depression and, you know, talking about their hypertension or all of those things and do, you know, changing their medications, you know, using My brain to listen to them, to form a. Form a plan that is not as highly valued. So for me saying, well, okay, if it's not highly valued by insurance companies, well, I'm going to see if the patients value that. Well, they do. And so they're willing to pay me for that. You know, why is that somehow less than for somebody getting paid for, you know, somebody breaking their bone? I don't know.

It's like a great example of that. Like, we used to talk about this when I was in the traditional model. So, you know, the doing versus the thinking. So. And what's harder? And both can be difficult. And I don't want to, you know, demean anybody else's profession at all. But, Sarah, I know you've heard this. So back in the day, like, the. The most reimbursable thing I could do was to reduce a nursemaid's elbow and a toddler. So, you know, nurse mates, you know, where they sublux the radial head. Like, usually somebody picks them up by the arm. So literally to fix it, you supinate and bring their arm up and they're fixed. And it was like a $450 bill, and it takes like, three seconds. So. And versus someone I see for diabetes, hypertension, heart disease. And by the way, they're depressed and they just had some chest pain, so that's. That. That might get me like, $90, you know, so. And it's like. And it's. It's. I hate to reduce stuff to dollars, but. But it does sort of explain that dichotomy between thinking and doing and how the. The billing model kind of evolved that way. And now we're stuck with it. It is just what it is. And people go into different fields. I mean, I went into family medicine knowing that it wasn't a highly lucrative field. That's. That's on me. And I'm. And I was fine with that. I'm still fine with that. But it is worth mentioning that there's this huge disparity in how services are valued.

No, for sure. And I think it just going back to the shortage of primary care physicians. Like, we talk about the shortage and this shortage, but, I mean, I see from my class, I see very little talk about people wanting to go into primary care. So I think it is important to be able to show these alternative routes to try to get more people to do it.

Yeah. Because we're in trouble if they don't. Right?

For sure.

Yeah. Well, and Stephanie and I have talked about that, too. You know, in these Big tertiary, I mean the medical schools are in big tertiary care institutions. I mean, they're not doing a lot of primary care there. And so, you know, it doesn't, you know, then, then people kind of think, oh, family medicine. Well, you just see a bunch of colds and stuff like that. And you know, that's really, certainly I do see that, but that's a, that's a really a tiny percentage of all of the things that we do. And so I don't think that it, you know, then by the time they actually do their family medicine rotation, probably late in the third year, they've kind of already crossed it off the list. You know, they just don't think it's going to be interesting. And they're, you know, they're already trying to work on their ortho applications.

Yeah, it's true. That's absolutely true. So I, yeah, making it more attractive because it's, I mean, it's a wonderful field. Like, it can be so rewarding. And now, you know, in this model, because I have fewer patients, I can spend more time with them, but I can also spend more time doing other things. So I'm actually more, I'm more present when I'm here. Right. You know, it's like you've had some, you, you've been able to, to do other things or pursue other restful and, or stimulating activities and now you're, you're more 100 on and that's, it's almost not fair to your patients when you're not, because it's tough, you know. And you know, you guys know this like every, you know, every time you enter a room with that new patient, you got to start over and you got to be on, you got to be ready, you got to be listening, you got to be looking for non verbal cues as well as verbal cues to try to pick up on, you know, and people's communication skills can vary greatly. You know, how people describe their HPI can be very circuitous. Right. We know those patients. So it's so much, it's not fair to be super frustrated those patients because you only have 15 minutes. Just like, that's just the way they talk, you know, it's like that's not their fault.

So I find myself doing that so much that the, the nonverbal cues and the, I think about this like when, you know, patient tells you something and you're like, okay, I've got to tell them what the plan is. And I know they're not going to really like this plan because they were looking for a different plan. And then you've got to like sell your plan.

You need a little time to, you.

Need to, and you've got it. And sometimes you're, you're, you're starting to get into what you think the plan, you know, what, what the plan is going to be. And you're reading their face and you're seeing that like they're having none of it. And so then you're like, okay, let me, let me shift gears a little. Let me find something that's going to be a little bit more appeal, appealing to them. And, and I, I just think about that, about how you really, you don't think of yourself as like in sales, but you know, when somebody comes to you and they're like, I want an MRI because of this or that and they don't need an mri again, you know, if my patients really want an mri, it's no skin off my back to order it. But at the same time I'm like, you know, here, this is really, we need to do this, this and this. If that doesn't work, we'll do the mri. But you just got to kind of like, you know, you just gotta sell it. But they have to be on board with the plan. If they're not on board with the plan, you have wasted the entire time because they're not going to do what you say. And you know, and then the whole thing is just, is, is just a waste. So I think that all of those communication skills are just, they're just critically important.

They really. And like I often say, some of my best training for being a doctor was waiting tables and you know, to being a cashier at a grocery store because you talk to people and you kind of learn some of them want to be talked to more, someone want to be talked to less. And you kind of learn to read people's non verbal cues about when they're getting frustrated, when they're not, when they're buying in. And Sarah, that point you make about the cell, it's like that's, it sounds crass to say it that way, but it's so important because you need them to be that you need them to be participating in the care plan that you've laid out. So if they're not, it's not valuable and you got to regroup and yeah, and we, we don't, you don't always succeed, but you have time to try to set that up. So in, in a 15 minute time frame. You really, sometimes you don't, you Kind of like, okay, this is what we're doing here and this is what we're doing here and let's see you back in a month and see how it's going. And you don't really get a chance to parse those non verbal cues or even, maybe the patient even hasn't had enough time to ask enough questions because a lot of times they don't know right away. And it's like how many times you're walking out the door and they're like, oh, you know, and that's back in the day that was so dreaded, but now it's just like, yeah, okay, we're good. Sit back down, you know, look them in the eye and talk a little bit more.

So and I think that's, that's the huge benefit of that longitudinal relationship that you have with the patients. They remember that we, we did this before and you know, I really do know what I'm talking about. And there's some trust there. So that when I say something and they're kind of like, oh, you know, that's not what my friend told me to go and you know, get this medicine. And then I'm like, yeah, but you know, here's, here's why we should do this and that. And, but when you have that longitudinal relationship, they're like, okay, yeah, I'm willing to give you the benefit of the doubt. I'm willing to try that. I don't see how you can build that relationship when you only have a few minutes each time. Even if you are seeing patients for multiple years, which a lot of times you're not, because you accept this, these particular insurance plans. Well, their company changed insurances, you know, two years ago and so they had something different. Well, they weren't on your plan, so they were seeing somebody else. Well, now they bounce back to you because their company changed again. And so all of that just completely disrupts all of the doctor patient relationship, which then does affect the, you know, it just affects their care, which is all those, all those frustrating things.

Yeah, 100 and another thing that's really fun. And what I do now is like sometimes you get something weird. Like I had something weird yesterday, it's like super weird. And you don't know. And it's also, it's so liberating to tell a patient like, hey, this is weird. I don't know what this is. But you and I are going to sit down here and we're going to do a little research. You know, we're, I'm going To look what does it sound like this? Or like I'm going to get online and I'm going to consult up to date or any on a number of reference sources and we're going to come up with a plan together and we're gonna, and we're gonna make sure that we both feel comfortable about this going forward. And maybe, you know, I get a specialist on the phone while you're in the office. It's like, that was never doable in the old model. Maybe people can. And there are people that are certainly more efficient than I, no question. And not knocking people who are doing that job well every day. But I so enjoy that part because like, like something some patients may never want to hear their doctor say they don't know. But it's also, you can build super amount of trust there because like, I don't know. But I'm with you. I'm sticking with you until we get the answers to this. And that's so valuable. And it's valuable. It's a value for the patient, but it's a value for me. It's like, then you get this really warm, fuzzy feelings about it because, like, you're, you're in this, you're going to war together and you're going to fight this thing.

So, yeah, I think, I think patients do appreciate that. They appreciate when you say you don't know because the other times when you do say, you know, they're like, well, okay, she does know. Exactly.

Because she'll tell me if she doesn't.

Right, right, right.

No, all that stuff. I just think we, if we can empower younger physicians like you, Stephanie, who are, can recognize the. These really cool magic moments you can get out of this and how rewarding this career can be and it doesn't have to be looked down upon. And like, you mentioned that a lot of, a lot of your colleagues bag on family medicine. And we heard that, you know, we're sort of like, we're the low end of the pay scale and we're kind of like, we know a little bit about everything but not much about anything. You know, you kind of always heard that. But it's, it, it's. It's not that way. It's like, it doesn't have to be that way. You can really excel and, and research and know a lot about your patients in this model. And it's, it's. If we could just get that message out to young people about how cool and exciting that is.

Yeah. Something stuck out to me when you guys were Just talking about this is. That is just going back to the cell and how you have to sell your patient the plan because if you don't, then this was all a waste of time. Do you feel like there's anything set up in the medical education that helped you, like, be able to do that?

So I think volume. And you can speak, maybe you can speak to this too, Sarah, but the volume that we had at Florida or high volume centers, you kind of had to learn to be efficient with your messaging and, and, and say the right things and try to read people at the same time. So it kind of taught you on the fly. But. And that's more of it in a hospital or an emergency room setting. But I didn't, I didn't feel like there was a strong part of that in the outpatient because our, because our schedules were so full. Didn't you feel that way?

Yeah, I don't know. I don't even ever remember anybody talking about that or anything. In fact, yeah, I don't remember any medical education.

No, true. There was no formal education that said you have to think about the cell or anything like that. That, Yeah, I was thinking like we, we all sort of intercalated it on our own. But yeah, I think that would be a great ad. Adjunct for teaching young people is, you know, how to, how do you get your patients to buy into the plan that you set up and make it collaborative because it's always going to be successful.

So much of that is like, really, you know, for us, like, we know our patients and so you kind of know what's going to work and doesn't work. But if you're just meeting the patient, just kind of trying to figure out those things about them, like, okay, what, what is it that's going to really appeal to them? And obviously getting them to, you know, they've got to partly come up with the plan or help you when you sort of throw different things out that you have to kind of see what they really latch on to. But again, that just comes to like reading, Reading the patient. I don't know. I mean, a lot of people in medicine I don't think are very good at a lot of that stuff.

I wasn't gonna say that. But. But I, but I kind of. Yeah. And I think it's time and you know, different personalities, people have different skills, different people skills. But I mean, people, people should be family medicine people. I mean, at least they should consider it because people can come to you with anything. And that's such a, that's such a cool thing because you get first crack at the puzzle. You know, you get first shot and you can make so much difference. You can, you can quickly decide, hey, this needs a X, Y or Z specialist. Or I've got to, I've got to work on this. But then I got to put it all together. It's, it's a really, it's a really cool field that way.

Yeah. And I hate to keep going.

Oh, go ahead.

I was just going to say, like, I hate to keep going back to this, but it is kind of frustrating. Yeah. When you see these people, people and these people who would be really good at something like family medicine, and they, it's totally crossed off the list, not even a consideration.

And maybe, maybe one of the answers to that is to try to partner with residency programs, to have, have students that have an inkling, let them come see a day in the life of a, of a, you know, private pay family doctor.

I know the. I, I am signed up as a preceptor with the Texas Academy of Family Physicians. And so they, they do come to me and say, can I have, can you have a student rotate with you? Which I'm happy to do. My problem is I have such low volume that I, I tell them this is a great elective, but I can't do it to count as their family medicine rotation because I just. They're just not going to see enough of all the things that you see in family medicine.

Right.

But honestly, that's kind of. I don't know, maybe I need to find some way of, of doing that simulating patients or something else because that puts more burden on those other do who do a traditional practice who are already, you know, in this time crunch and now they've got, if they're having a student rotate with them. You know, we all know a good med student only doubles your workload. So, you know, it's just, it's hard to have a student with you. It slows you down. And even if it's fun, it's just, you know, it's more work for them. So I don't know, I really need to, I need to noodle on that and figure out some way that I can kind of participate a little bit more.

Yeah.

And have it be really beneficial.

Let me know what you come up with, because I've run into similar issues because like, I've told people flat out, like nurse practitioners who wanted to try to get their credits or, or young doctors. It's like, again, it's not enough. You're not going to get what you need to get. Like, we can have fun and I can show you a lot of stuff and I can try to motivate you. But that is probably, but again, as an elective. And then the other barrier is some of the patients don't. They really want me, you know, so they don't necessarily, they don't necessarily want to go through their history with two people that day. So. And they'll be, and I, mine will definitely be bold about saying if they do or don't, you know, I have.

A few that, you know, say that's fine, but, you know, I mean, and again, sometimes in this type of practice you have some high profile patients and they really, really value their privacy and, you know, they just don't want another person in the exam room. And I completely understand that. But I don't know, I don't know, maybe, maybe that, that, that time period between first and second year when students are, they do have a little bit of time. They're supposed to be doing research these days, apparently. But I did have this one student this last summer. Do I, I just did like two weeks with me, it was mostly just me gabbing, but I don't know, I think I imparted some knowledge on him and then he had to be on the podcast. That's I. What part of the job.

Yeah, there you go. Well, I was just going to say I have got a great idea for getting a message about coner medicine. Like somebody should start a really cool podcast that a bunch of medical students watch and then maybe the message gets out that way. Now you. Yeah, this is a fantastic model. Stephanie, do a lot of your friends, do you have a lot of people who tune in?

Yes, yes. I mean, we're like more and more reaching a wider audience. Definitely. A lot of my peers do. And yeah, just getting like more and more other doctors who kind of have big followings we've had on the podcast, which has grown us a lot. So, yeah, it's a lot of like different types of people, but definitely a lot of med students.

Yeah. So to flip that dialogue on you, like when you encounter people who are pretty nag on family practice colleagues, wise people at your level, did they try to dissuade you?

Yeah, I mean, we've talked about this before. It's a tough conversation and it's hard to respond because if I say like, oh, I might be interested in family medicine, it's the thing of, oh, that's so good for you. Like, that's so Great for you doing that. Like, I wish that I could go into primary care, but, like, that's like. But you're so great for doing that. And it's just a hard thing to kind of respond to and a hard thing to, like, figure out how I feel about it.

Yeah. Because it's like they're. They're saying you're making a sacrifice by doing it. Right.

Yeah.

No, not really.

Very condescending.

Yeah. Yes. Yeah, exactly. We're used to that.

Part of what's in there, too, is this kind of thing of like, oh, well, are you not smart enough to get the good grades, to get the high test scores, to get into a more competitive specialty? And so. And which. That just, you know, that really does bother me because, you know, I feel like Scott and I were smart enough to do anything. We chose family medicine, you know, and I certainly don't think. I mean, I have many, many wonderful colleagues in all kinds of different specialties, and I never feel like they are, you know, that I'm less than them in any way. I don't know. Maybe they think they're better than me.

I doubt not you, but. So this is a fun thing. This is. This is a little. So it might help people motivate to consider family medicine. Not. But I'm still going to throw it down. So I love it when you get to interact with a specialist whom you've not met before, and you can just throw down, you know, right there in their field and know all the latest and all the stuff and have the patient prepped, and then you immediately garner a level of respect that you can tell that they weren't prepared to give you. Have you ever had that experience?

You know, that's a good question. I don't. I've been doing this for so long that I have, like, my whole list of specialists that I refer to who either they really do like me and respect me, or they pretend that they do because they want my referrals. I'm not really sure which it is, but they're very, very nice to me, and they always say, oh, thank you, and great pickup and blah, blah, blah. Again, I have no idea if it's legit. I feel like it is, but I don't know.

And with. And to try to save us from sounding like we're tooting our own horns too much, like we have the time and the luxury to know our patients really well, so we can give a very cogent argument or presentation to a specialist about what we've done, what we suspect where we. Where we need their input. So it's not just all about how great, how great Sarah and I are.

Yeah. Although that's a lot of it. But the. But no, I agree. You kind of. You do. I mean, I do all the, you know, I've. I've looked through it and, you know, Googled stuff before I ever even, like, you know, send it to them. Whereas when you do a traditional practice, you know, you're just. You're just getting beaten down. You're just like, I don't know, they got something cardiac going on. Send them to cardiology. You know, you just don't even have time to think about it. Oh, there's something abnormal in this cbc. I don't know what it is. Send them to hematology. But we have a lot more time and energy to look through it and get all that work up before we ever send them there.

And, and what, what you're saying, just so you. You hear this, Stephanie. It's like in the old model for me that, oh, this one needs a cardiologist. It's literally checking cardiology. Consult on a super bill, and then you're going into the next one. So that was not very rewarding. Like, you don't get any of the fun part. Like, what might that be like? Let's try to figure out this puzzle. So, yeah, and spending some time, like, doing the actual medicine part, doing the diagnostic part, that's the. That's that and, and reaching people and partnering people and having people trust you and, and want to. You want you to be. To lead them in their health. That's so cool. And it's like, so many times I revert back to this stance when I walk into a room. It's like, if somebody is overweight or their diabetes is uncontrolled or they're smoking or you name it, you know, lifestyle stuff, that's really, really hard. It's like, I walk in that room and I think, what does this patient need to hear from me today that's going to help them make the changes they need to make? You know, it's like sometimes they're not ready, but it can. The right words to the right person can make the difference. Just like a teacher, like a. A really, really effective teacher can be transformative for young people.

So, one. Yeah.

100.

And I think, like, having the time to be able to, like, remember that is so important, because words that you hear from physicians, like, I don't know, when you're seeing so many patients a day, like, you can Kind of forget that. Like, that's so impactful for every single patient that you're seeing.

Yeah. Yeah. Hey, Stephanie, are your classes like. Like, are a lot of them virtual or most of them in person, or is it a mix?

It's all virtual. They have, like, class. Like, there's class going on right now, but, like, I'm not there. Like, so they're all recorded so I can watch them at any time.

Gotcha. So you. You don't often have to report to a. Like an auditorium and listen to a lecture?

Yeah, there's a couple required things that we have, but for the most part, no.

How do you both feel about that, Sarah?

I. I think it seems nice. You know, I went to med school in Kansas City, where it was real cold outside, and I fantasized about being able to just, you know, turn on a tv. That was how I would imagine it, you know, turning on a TV and watching my professor. I was like, that would be amazing, you know, because really, in those lectures, it's not like you're really getting interaction with the professor. I do think they do some. In some of her classes, they do that flip the classroom thing where you watch the lecture online, then you go to class, then you can actually ask questions and interact. And that, to me, seems really helpful.

Right.

But just being there in person, I don't know, sitting there, listening. I mean, God, don't you remember just, like, dozing off and then you kind of come back and you're like, that's. That's really. You're not getting anything out of that.

No, I. That's absolutely true. And many times, like, I would even not go to the lecture and I would just memorize the notes or try to memorize the notes of the class while I was there. So that's no different. But it's. It's not so much what you. So the part that I worry about is not what you're necessarily getting from the lecture, but it's the bonding with your. Your colleagues. It's like, so do you feel like you know everybody? Well, maybe at this stage you shouldn't, because it's so early in. In medical school, and you get really more of that when you do your clinicals, I guess, but I don't. It's something about everybody being in the same room. Obviously, anatomy lab is going to build some of that. You can't do that online, so.

No, yeah, 100%. That's what I. I agree with that. I do. It's just like a time thing. Like, I can watch lectures on two times speed and watch them in 25 minutes versus, like it taking 50 minutes. And yesterday I did screen share. I was sick and I was laying on the couch and I did screen share the lectures to my tv and I was sitting there just watching them. So. But it's true at the beginning when people went to class in the first couple weeks, so it was good to meet people. And I think I am outgoing and the type of person to get out there and put in effort to meet people and build relationships. So I think for me it's easier. But I think maybe for other people, I mean, this semester we have anatomy labs, so we're spending a lot of time on campus. Today I'm dissecting later, so I have to be here. But next semester when we're done with anatomy, like, some people you literally, like, will never see them. Like, there's no point in being on campus. So. Yeah, it could be weird.

Yeah. Pluses and minuses. Yeah. Different times, but yeah, that's.

I. I do agree that's not great. There was some camaraderie that you had and just sitting there all together, you have some breaks in between and. Yeah, I don't. I don't like the idea of just everybody being by themselves. And again, Stephanie's social. You and I were social, Scott. We would have been. We would have been fine. But there's a lot of whole big group of people that really are not. And are not good at reaching out. And I don't think that's very good for them.

No. I know a person who's been involved in faculty for residency education and training locally, and it's like the mental health stuff is bad, bad for young, young aspiring doctors now. And so I and Covid just, you know, put an exclamation point on all that. And hopefully the value of not being isolated or the value of sitting in a room and sharing ideas is they're gonna at least keep that alive. You know, I think that the. When. When you said I didn't even think about. Because it's like our generation, Sarah, we don't think about it. Like you can listen to a lecture on 2x. Like, wow, think of that. You know, it's like, that's fantastic. I wish I could do my CME stuff, you know, that after. Yeah, that's fantastic. So. But maybe there'll be a mix, you know, because, like, you want. Especially when, you know, I don't know how it is like nowadays. Like, are hours truly less than what we did, Sarah? Is that True. Do they protect resident hours or medical.

Student supposed to be? I don't, I don't know how much you know about that, Stephanie. I mean I, you know, it's supposed to be a max of 80 hour work week. Although I have heard that there are ways that they kind of get around that at times as well. I don't know. What do you know about it, Stephanie?

I don't know much. But yeah, I did hear that they cut it to an 80 hour work week and your generation is all upset because they're like you're not gonna be able to get all the info that you need and stuff.

So I don't know, I mean, I'm all for it if you can get the info you need. But you know, there's, there is something about like sometimes when you're practicing, you're going to be sleep deprived, you still have to make split really good decisions. You know, sometimes when you're practicing doctor, you're going to be stressed out, maybe you're getting a divorce or whatever and you're still going to have to make life or death decisions. So I think some of that kind of in the trenches training is good in that way. Maybe we can find a happy balance between the two.

Yeah, I think, you know, a lot of the research shows like when, if you are a practicing doctor and you're experienced and you are sleep deprived or have other stressor stressors, you've got a little bit more resiliency to it because you're not learning. You already, you're doing what you already know when you're a learn. You know when you're learning like when you're an intern and now you're sleep deprived and have all your other stressors, you still might be going through a divorce or anything else during that time, then that's when you really do make mistakes because you don't have that, you know, fund of knowledge to rely on. You're, you're new, you're learning. So you probably can learn a little bit better if you've had a little bit more sleep. Now there's something to be said for the fact that you just have to, well, there's all the work that needs to be done is a lot of it and that just people, you need to be on site to see a lot of things and you just can't do that unless you're spending a lot of hours there because you don't know when things are going to come in and all that. So I think there's, there's something to be said for that. But you know, when it's arbitrarily difficult, that's when I'm kind of like.

Or just making it difficult. To make it difficult is.

Yeah, right.

There's no point.

I don't.

Depends. I think I, I'm, I'm agreeing with you. So it's like there's some of it might be okay and some of it just for the purpose of, of making people go through what you went through was dumb. But there I, there is some, there is something to buck up and put up a little bit, you know, you. Because like, what if you're an hour late and you walk into the third straight room where people are yelling at you for being late and they still have heart disease and depression? You know, it's like you gotta, you got to have some built in strength to kind of, to put up with that and keep working. Because if you don't do the work, somebody else is going to have to do the work, especially in residency.

So, yeah, I think it, we kind of talk about this a lot, going back and forth between that sort of thing. But before I start residency, I'm in all of that and still have a long way to go and very far from even the hardest part of all of this. I asked all the guests this. Do you have any advice for like somebody in my shoes or for any of my peers listening, like before we, when we're at the beginning of this whole medical education journey for me, like.

Remember why you're doing it, because if you're not doing it because you love it, you're doing the wrong thing. So remember, always keep that because it's like if you're, if you have the interest and you want to serve people and you like the service aspect and you like the science aspect and you, you get your jollies from helping people, that's going to sustain you. And then otherwise, just you. All of us start with an idea of what we think we like, or maybe what we think we like, but keep an open mind and try to walk into every rotation as you know, hey, let me see how this feels. Let me walk in these shoes, see how it feels. So. And then decide what really, you know, makes your heart sing at that point. Did I just say makes your heart sing?

I liked it. I thought it was great.

Okay. Okay.

As we're, we won't take up too much more of your time, but do you have anything that you want to plug on the podcast? You got social media, anything?

Oh, gosh. So sure. I didn't prepare for that. So my practice at capacity, but I have another doctor who works for me. Her name is Allison Skerzinski, so skersinskyfamilymedicine.com she's wonderful. So anybody in the Pennsylvania area looking for a concierge doc? She's awesome. And I also run an aesthetics practice, so we didn't even talk about this, but so I learned to do aesthetic procedures, initially Botox and fillers, but now other laser rf, which stands for radio frequency energy. That's used to tighten skin. So we have those kind of devices around too. And so sets or aesthetics.com you can follow me on Instagram. I'm learning to post more, but it's been really fun.

That's awesome. I definitely might want to talk to you about that at some point because that's something that I'm interested in.

Yeah. Yeah. That might be another podcast, right?

Yeah. There you go. We'll have to have you back. You know where to find us @Generations MD on TikTok, Generations MD on Instagram. And if you have any questions or interested in being a guest on the podcast, you can email us@askgenerations.mdmail.com and we'll talk to you next week. Bye, guys.

Bye.