Interview with Dr. Kara Pepper – 454
In today's interview, Dr. Kara Pepper describes how to thrive in a micropractice and why you should follow her lead in doing so.
A former employed internist who left a 70-physician multi-specialty practice in 2022, Kara built a cash-pay hybrid practice from a 150-square-foot office that now serves patients across 17 states. She covers the business model, staffing structure, niche development, and how she navigated a non-compete clause that nearly blocked her from seeing patients in her own city.
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Building a Micropractice from Scratch
A micropractice operates with a small patient panel, minimal overhead, and no reliance on insurance billing. Dr. Pepper's model is cash-pay on a per-visit basis; not a retainer, and not a subscription. Avoiding insurance companies keeps the administrative burden low and eliminates the requirement for 24-hour coverage. Her current panel sits at around 650 patients across 17 states, seen through a hybrid of in-person and telemedicine appointments, five days a week, generally between 9:00 AM and 4:00 PM.
Staffing follows the same lean logic. For the first two years, she operated solo. She has since added a virtual operations manager, a nurse for clinical support, and a full-time virtual assistant who handles scheduling and phones. Her newest addition is a physician who wants to build a similar micropractice without startng from scratch. Overhead stays low, pricing stays accessible, and each hire is made deliberately rather than reactively.
Her advice: hire earlier than feels necessary.
Marketing, Niche, and Practice Growth
Dr. Pepper has been running this for years, with rapid growth and virtually no paid advertising. The model is relationship-based, building referral networks with dietitians, therapists, and other physicians through direct outreach, shadowing, and speaking engagements.
Kara believes that identifying a clear niche accelerates that process. Her practice evolved from a general eating disorder focus into a specialty clinic addressing other complex conditions.
Prepare to Thrive in a Micropractice
For physicians considering a similar path, market research matters before launch. It helps to understand the local price point, the patient demographics, and the competitive landscape.
A cash-pay model that works in a major metro may not be viable in a lower-income rural area. When leaving an employment relationship with non-compete clauses require early legal review. Kara navigated hers by launching exclusively via telemedicine in out-of-state markets before eventually returning to in-person practice after the restriction period ended.
Summary
A micropractice does not require a large team, enrollment with large payors, or a traditional overhead model to be sustainable. Dr. Pepper's practice runs lean by design: cash-pay, hybrid in-person and telemedicine, a small panel, and a virtual support team. And it grown entirely through referrals and relationship-building.
The key decisions that made it work: identifying a clear niche, hiring deliberately, treating the practice as a real business from day one, and using the non-compete period productively to build out-of-state referral networks. For physicians considering a similar move, she runs a Micropractice Mastermind and hosts the It's Not Just You podcast. Resources are linked below.
NOTE: Look below for a transcript of today's episode.
EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.
Links for Today's Episode:
- Dr. Kara Pepper's LinkedIn Profile
- Kara's Website
- Kara's Mastermind Program
- It's Not Just You Podcast with Dr. Kara Pepper
- Free Resources About Creating a Micropractice
- How to Build a Micropractice Free Webinars
- Dr. Kara Pepper's Medical Practice Website
- Highlights from the Nonclinical Career Summits (19 presentations about nonclinical and unconventional options)
- Nonclinical Career Academy
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TRANSCRIPT EPISODE 454
How to Thrive in a Micropractice
Interview with Dr. Kara Pepper
John: Today's guest was a traditional employed internal medicine physician who, for probably reasons similar to many of us, decided to leave her practice in 2022. Now, before she left, she did become an executive coach, so we're going to talk a little bit about that as well. But the main thing I'm interested in today is to hear about what she transitioned into. So she's been running what she calls a micro practice. It has different features to it that are very interesting. and she also helps other physicians to do what she has done. So, Dr. Kara Pepper, welcome to the PNC Podcast.
Kara: Thanks for having me. I really love what you're doing to support physicians. There's never been a better time than that.
John: Yes. I thought maybe when I started this, you know, things would get better, but I don't know. There seems to be more and more incentive to change. However, at the same time, there's a lot more resources out there for physicians who are looking to maybe shift one way or another. And you've got some things that we can talk about. But first, we have to talk about your story, about how you became a physician, and then why you ended up leaving your initial practice. So why don't you give us the, well, the medium version of that lengthwise.
Kara: The medium version. Sounds good. Well, you know, I grew up wanting to be a professional ballet dancer. I never thought I would go to college. And I left home in eighth grade to train to be a ballet dancer in Russia. And came back and went to like a boarding school for ballet dancers and then got a job. But it was amazing. But because of eating disorder-related injuries, I kept getting injured and I could not keep dancing. And because I was a patient of physical therapy for a long time, I thought, well, maybe I'll go to PT school. And my orthopedist said, I think your personality is better suited for medicine. So I applied to med school. That is the extent of what I knew about med school. I had no doctor mentors. I had no idea what I was getting myself into. But as it turns out, dancers and doctors are the same people. You know, we show up at work every day trying to get a little bit better at what we do. We learn the technical aspects, but really it's like the art of application.
Everyone applies things a little differently there's lots of perfectionism lots of workaholism so it was really easy transfer. I looked good on paper in many ways in med school and residency and in my early practice, thought I wanted to be a teacher but also really value autonomy, so I ended up in private practice. And it was the right place for me at 30, but it really did not end up being the right place for me by 45. I wanted to be able to fix problems. I wanted to be able to pivot easily without a big bureaucratic system. I wanted to shift my practice as my interest grew and I evolved as a person. And I had opened the telemedicine line for our big 70 physician multi-specialty practice, and then COVID happened. And all of a sudden, we were all home doing telemedicine, as everyone here knows. And I was like, this is the best medicine of my entire career. I actually have time, I can talk to patients, I can put together the pieces of the puzzle without feeling eternally rushed. And in the background of all that, I became a coach really as a product of my own burnout. I wanted another skill to try to help patients, but physicians kept coming to me like I had the answers to some problems. And so I built this coaching practice kind of unexpectedly and ultimately had to take my own advice, which was, listen, like, life is short. You could be dead showing up at work next week in this pandemic. And even though it looks good on paper, it's not what felt good anymore. I, you know, my kids were growing up, my parents were aging, and I wanted to have a life that I didn't regret. And so I left and started my own telemedicine practice.
And the big caveat with that was that I had to start a telemedicine practice because of my non-compete. There was a big limitation. And so it was the way that I wrote out my non-compete for two years. Started an eating disorder practice, which very rapidly evolved into this MCAS-POTS-Ehlers-Danlos practice. And after two years, I went back in person, which is where I'm broadcasting from right now in my 150-square-foot office space.
John: Nice.
Kara: Yeah, it's great. And so when I say I have a micro practice, I truly mean that. It is a very small footprint with a very low overhead. But in 4 years, it's grown to 17 states. I've hired another doc. We have a team that's entirely virtual that supports us. And so it's a way for us to be able to practice medicine on our own terms in a way that's healing for us and takes care of the patients we really love taking care of. That's what got me here, and there's lots more to say about that, but it's a world that I've created that allows me to love medicine again and feel like I'm in charge of my own destiny and can practice the way that I want to, which is really part of my core values. So, it's fun.
John: It's a nice story, although maybe the part where you weren't feeling well for too long is not, but it's so common for physicians.
Kara: That's right.
John: I think my mentor was Dr. Kildare or one of those guys on TV. I had no mentors. I had no one in my family either. I kind of relate to a lot of things you said, and a lot of the people I've worked with over the years just got burned out, basically, moral injury, whatever you want to call it. And, no, it's great that, you know, you took the bull by the horns and then said, okay, I'm going to do something that really aligns with what I want to do and what my vision and mission in life are. Okay, so we get that you left the old and you started this new and you took advantage of the telemedicine, which is awesome. So what does your practice look like now in a little more detail? What is it like every day? You know, what does that mean?
Kara: Yeah, so I had done this coaching exercise when I was burning out like back in 2016, 2017. And someone said like, just like, wipe the slate clean. What is a perfect day for you to feel like? What's the pace? What will you not be doing? You know, who are you with, etc. And I like very kind of like secretly wrote out this plan of like, I want to wake up and not chart first thing in the morning. I don't want to pre-chart before I show up at work. I want to drink hot coffee before it gets cold. I don't want to feel rushed. I want to work out. and then I want to start my day and I want to sit down and actually eat lunch and have a chance for my brain to recoup before I start the afternoon and then I want time afterwards. And I was like, that's not possible. I mean, that's just not how medicine is built. And the truth is, that is literally what my day is like now. I wake up, I have to get my kids on the bus and then I work out and I show up at work. My first patient's at 9 to 10, depending on the day. I see patients basically 9 to 12 and then 1 to 4. So I take a full hour in the day for lunch and administrative work.
And yeah, I have some business of medicine stuff that I have to do after that. But, you know, I've created a life that feels good and I can see patients in that window of time. My business model is outside the insurance industry. So it's a pay-as-you-go model. So it's not a retainer. It's not a subscription. I'm not a DPC doc. It's like therapy. It's like Amazon. You know, you pay and then that's it. And for me and the patients that I take care of, that's the best business model in terms of the arc of the patient experience.
And for those reasons, I really like it. But I think culturally, it's kind of ends up in the DPC world, even though it's not formally a DPC practice. And, you know, the coaching part that I had done for a while, supporting physicians through career change, you know, it went from talking about burnout and perfectionism and imposter syndrome, really to people saying like, I want to do what you're doing. You know, how can you just, can I just have 30 minutes of your time to like sit and pick your brain? And I realized that so many physicians are, even though we're seeing all of private equity and venture capital buying up private practices, so many physicians are saying, that's not working for me. I want to be able to take care of patients the way that they deserve, the way that I deserve.
And for a long time, we've seen that happen in the DPC space. But now we're seeing this real expansion for specialists, especially proceduralists, who are, whether or not they're taking insurance or not, who are stepping off and saying, I can do it better. I don't have to have this massive administrative overhead. I can leverage technology. I can leverage resources and shared resources, even fractional CFOs, where people are saying, I can do this in a lean budget model so that I can practice the way medicine was meant to practice. And so it feels really, really good to be able to support people who need a road map in that way.
And I'll tell you, I've made many mistakes. My husband's not in medicine. He's an MBA. And so when I quit my job and said, hey, I'm going to start this practice, he was like, what's your business plan? And I was like, the plan is that I'm going to make money and see patients. And he was like, oh, my God, that is not a plan. That is WISHFUL thinking. And so I certainly didn't know what I was doing. And there was a lot of bootstrapping. But that is not necessary now. There are so many Facebook groups, conferences, micro-practice masterminds like mine, but like business communities for physicians saying like, you don't have to reinvent the wheel. You can have this roadmap that's laid out for you if this is what you want. And to be clear, private practice ownership's not for everyone. Like some people just want to be a worker bee. They want to show up. They don't want to have to deal with HR issues and things like that. That's perfectly fine. But for those of us who value autonomy and really want to do it different,
You just get to choose your heart. Do you want the heart of not being able to make the decisions or do you want the heart of being able to make decisions? And I think we kind of fall into one of those two categories.
John: You know, I have a lot of questions just based on what you said already. I'm going to go way back to the beginning of when we started this because this comes up a lot when I talk to other physicians who are thinking about doing something. Did you, when you were thinking, okay, I'm reaching the end of my rope, did you in your mind know you had a non-compete, knew the specifics of it, or was that like something where it was like a rude awakening at the last minute that, oh my gosh, I forgot, I can't really go so much?
Kara: Oh, no, I was well aware. And, you know, whenever you're making a big change, you know, there has to be enough incentivizing energy to get over the discomfort of change. And so every day I'd come home and be like, you know, to my husband, yeah, I'm so burned out. I don't want to do this anymore. He would be like, but the non-compete, but the pension. I got a pension, still have, I guess, a pension through my previous job, right? Like, they really were trying to keep us there in those systems. And so we would point to these things and say, well, I guess, you know, those feel too big to get over. I might as well just stay here until I had done enough personal work and had enough clarity to be like, this is actually not enough to keep me anymore. So, yes, I knew about the non-compete. And telemedicine still then, even though it was 2022, was still, the laws were still evolving around that. And quite frankly, my hospital system that owned my practice was like, try us. We would love to take you to court so that we can set the precedent for the state of Georgia. They were very kind of unabashed about that. And I think that is a real disincentive for people who are nervous about managing their non-competes. And anyone who says, oh, they'll not enforce it, I assure you, in the state of Georgia, at least, they are happy to try to set those laws. And so the telemedicine arm was the way to kind of navigate around that and allow me to still preface medicine, even if I didn't want to drive 20 miles away from my house.
John: Do you think they put a clause in their contract that says, well, you can't do telemedicine from home either? I mean, they do. Yes.
Kara: In fact, that is exactly what they did. They're, because Georgia is a pro-business state, what they said, the sentiment of a non-compete is to protect the business. So they said, any human who lives in your non-compete territory, even if you have no relationship with them, they are off limits. If they live within that non-compete area, even if they've never been seen by our hospital system, they are off limits because that is our territory. And so, ironically, I could have driven 20 miles, parked myself in front of their sister hospital, you know, another community hospital owned by the same system, and practiced there, but I couldn't see a telemedicine patient that never had a relationship. So, I mean, medicine is a business, and so hospital systems and private equity are absolutely trying to protect their revenue. And so, there's many ways around that, but that's how I did it. It's just like I'm going to do telemedicine outside of that territory.
John: That works because you're licensed in several states, correct?
Kara: Yes, 17 states.
John: 17 states. When you started the telemedicine, well, are you still doing that now a little bit?
Kara: Yes. Yeah, so it's a hybrid practice. So as I spent two years doing telemedicine, I got a reputation for the type of work that I was doing. I have referral networks in most of those states, and so they would send me patients. And so when I went back in person, I do think there is a deep desire for patients to be seen in person. They want the human connection. They want the healing touch. They want you to lay hands on them, even if for many of us, we don't, you know, our brain is our primary tool, not necessarily our brain and our hands. Anyway, and so I do a hybrid model where I show up in the office, I'm sitting in this chair either way. And some patients I see by telemedicine, some people walk through the front door. And it allows people to kind of choose what's right for them. And there's a lot to be said about how people make that decision. Yeah.
John: So you kind of talked about how your day looks, how many days a week you're working and like, what are the total number of hours you'd have to be available on the weekends? What does that look like?
Kara: Yeah, so call is a really interesting question. If you take insurance, that is often part of the insurance contract that you are required to have 24-hour coverage for your practice. Because I don't, I do not have 24-hour coverage for my practice. That was revolutionary for me.
I think for many people, they worry, like, I can't go into private practice because I don't want to be on call all the time. I don't want to be on call all the time. And as I went into a call for many years for a practice where I was covering 100,000 patients when I was on call, there is nothing I can do from home at two in the morning as an internist. I either need to send them to the emergency room or I need to say, listen, this is something that can wait until the morning. And I really felt strongly that medicine is a team-based approach. And if you're calling me in my solo practice, I'm not going to be coming in at two in the morning. So I don't take call. My business hours are nine to four. Those are the hours that I'm available. Outside of that, if there's emergencies, I will do my best to do that. Now that I have a doc who's joined the practice, we will share vacation coverage. But in the very early days when the practice was 50 patients, I'd say, listen, I'm going on vacation next week. Send me all your med refills. Send me all your paperwork. I will do my best yet at taking care of. And I'll see you when I get back. And I do think patients really appreciated being treated like a part of this community. Like, okay, great. She's a normal human. That's part of why we like going to this practice. But as the practice has grown, you know, of course, people have expectations, especially because they're paying cash to see me. But we still do communicate in that way, like this is when we're available and this is when we're not. So I see patients five days a week, nine to four, and that's it.
John: Well, I've been associated with urgent care for about 10 or 11 years. I'm not practicing now, but it always kind of struck me as, you know, we're here, we're seeing some pretty sick patients and we don't send them all to the hospital, but we don't have night coverage or weekend coverage either. You know, it's just like, it's just the nature of the beast and, uh, go to the ER if something changes and I guess that's all you can do. The nature of the patients that you see, is it skewed, you know, based on your interests and just word of mouth, would you say? Or is it a full kind of internal medicine breadth of conditions, would you say?
Kara: Yeah, I would say that it's evolved in the past four years. You know, I will be a primary care doc in my bones until I retire. But what I have recognized, I still do have primary care patients who follow me for my old practice, but really the sweet spot for us, I open to really serve adults with eating disorders and no one ever just has an eating disorder. They often have this very predictable pattern of comorbidities. And so this triad, which many docs are not familiar with, really is a big part of the eating disorder community. And so that's where our reputation evolved. And I do think that's really the mission of this practice right now is to serve this subset of internal medicine diagnostics. It's really an invisible illness clinic, but we're doing a lot of diagnostic testing and helping people figure out a unique plan forward. And even though I'm in Atlanta, a city of six and a half million people, it is wild to me that I am the only person in my partner doing this type of work. And so I really do think that's the mission of the practice for us to be able to focus on that. And so my partner does not see any, you know, if someone showed up on her schedule for a physical, she'd be like, let me just refer you out before you even walk in the door.
Because that's not what she does. But I still love my folks that I've seen for like 15, 20 years. And so I'll still see them because they're easy enough at this point in time. But I think, you know, like I mentioned, my husband's not in medicine. And when he graduated with his MBA at 27, if he was still in the same job that he had then, people would think there was something wrong with him. They were like, do you not have any ambition or desire to change or have you not learned anything in the past 20 years? And I think this fallacy, like when I interviewed out of residency, I said, we want to hire you and retire you. And I didn't understand it at the time, but I had this like bone deep kind of dread, like, oh my God, I've got to do the same thing every day for 30 years. It feels terrible, even in internal medicine, it's so broad. And so I have really appreciated the ability to augment my career over time, but particularly even in solo practice to be like, I think this is what I like doing. But over time, I'm allowed to say this is what we're doing now. And that for me has really kept me engaged with the work that we're doing. And I'm having the most fun I've ever had in my career. It's really, really interesting medicine.
John: I'm going to ask you, did you talk about this before you did it with other people, other physicians? Because I've talked around here, you know, about not me personally, but like saying, well, why don't you consider DPC? Or why don't you consider, you know, just private practice, you know, self-pay, whatever. And they're always like, there's not enough people around here that would be interested in that. Now, we are outside of Chicago. We're like an hour south. So we are in a little bit of a semi-rural area, but you're near Atlanta or in Atlanta. So did people sort of try to have you not do it, you know, discourage you, or did it take very long to build? What does that look like in the marketing and so forth?
Kara: Yeah, I think there's always going to be people who dissent because it feels scary to them. And by breaking the status quo, it makes people around you question, like, Maybe I could do that, or maybe I'm too scared to do that. So often, some of the feedback I got was like, oh, no, this is impossible. It's clearly not. That being said, you have to know your community that you're working in. What is the culture there? What is the price point there? You know, there's concierge medicine docs in Atlanta who charge $10,000 a year. Would that work in a very rural area with low levels of income? No, of course not, right? So there is a piece of market research where you need to understand your competition, what the culture is, what the general financial income of the communities are. But regardless of where you set your price points, there's a lot to be said that we talked about in the Mastermind about advertising.
But medicine is still very much a trust-based, relationship-based referral system. Everyone who's listening to your call knows when they themselves either have a problem or they're advocating on behalf of the patient, They'll ask, like, who do you know? Who should I send this person to? You know, they understand someone's brand. And so I've done...
I will say virtually zero. I've done one paid advertisement in four years, but otherwise zero paid advertising. It is 100% bent based on me making time because in the early days of my practice.
My schedule wasn't 100% full. So every day I was doing marketing, I would sit down with dieticians, therapists, other doctors and say, this is what I'm doing. Let's collaborate and building those trust-filled relationships. And one of the most fun things that I've done in the past four years is like kind of go back to med school. Like because I had, you know, a half day or a day where I wouldn't have had patients in the beginning, I went and shadowed people. And it was fascinating to me to like, one, build these relationships, but also like learn from our colleagues, teach them about what I do.
And I think at the core of it, we're all still kind of nerdy. We still like, if you're still practicing, you still like medicine and want to learn some stuff. And so it's been really fun to build these very professional relationships. And out of that, even in solo practice, I've published independent research, I've written papers, I have blogs, I've spoken nationally at all kinds of conferences on both medical and physician burnout stuff. And so to create this portfolio career that feels really engaging, it is like having an academic career, but I'm in solo practice. And it's just really interesting. So I think that's the take-home message. Like you get to figure out who you are at this stage in your life and what you want to do and do it by choice. That may mean stay employed. Okay, great. You want to stay employed because you don't want to disrupt your family and move your kids out of their schools? Fine. Just like understand that you're doing that by choice and taking the hits that come with that.
You want to start a private practice? Awesome. You're going to have to learn some new skills that you've never done before and that's okay. But there's no right choice, but you have the power. Like none of us are stuck. We all get to choose by choice what we do moving forward. And I think that's pretty cool.
John: So now, do you have any staff other than your new partner?
Kara: Mm-hmm. Okay, so I have a number of folks started with... So I hired a team of virtual assistants in the very beginning because I was leaving my old practice a new one. So I was like, I just need people to help me, like, set up the systems and integrate them. Like, I just literally need someone to answer the phone. So I hired temporary virtual assistants, and then once I got up and running, I let them go. And it was literally just me, no one else, for about two years. And that worked until the practice really was very busy. And that's not reasonable for me to answer the phones anymore. I would argue that by the time physicians think they need help, they've needed help for a long time. So my advice is hire someone much earlier than I did. That's another story. And so my first big employee, I hired a woman who was kind of a jack-of-all-trades person. I said, listen, this whole business lives in my brain. I need it to be out in the form of like protocols, employee handbooks. You know, if we're going to hire someone, we need an actual onboarding program. So you can think of her as like an office manager, an operations specialist. So she manages my inbox, she interviews people, she does research for me, she does my blog, she, you know, she kind of like runs the administration part of things. I then hired a nurse who was the patient-facing person, and she was answering phones for a while. But she now is doing a lot of prior auths, paperwork, calling with lab reports, clinical, you need a nurse brain stuff.
And now we have a full-time virtual assistant who's in the Philippines, and she's our phone person. So she's doing scheduling, answering phones, doing some communication stuff, basically like a medical VA, if you will. So it's been really interesting. One, I get to choose people who are the best fit, no matter where they are in the world. They don't have to be here in Atlanta. And also, it's a way to keep the overhead down. It's much, much cheaper to hire someone overseas than it is to hire someone who needs benefits and is sitting here. And so as the practice grows, I think the next most obvious person for us to hire is that we actually will finally need someone in person if we want to expand our service line, especially if we hire a third doc. So getting an in-person MA. And I think that for me is one, kept the overhead very lean so that we can keep prices down and still make a decent income. But it allows us to kind of think strategically about what our next hire is and how to create the right role for our practice that may not have a typical job description in a corporate setting.
John: You did bring on a partner, an associate, what have you, to go, you know, it's like 100% increase in staff kind of thing.
Kara: Yeah, that's right. That's right.
John: Providers, although it sounds like what they're doing is a lot different than what you're doing and not really mimicking what you're doing exactly. But what is your thought about that? It's difficult sometimes to share. It's, you know, do you see this, is this person going to be an employee or is an employee? Will stay that way? Are you looking at partners? What are you thinking about how that's going to continue to grow, and how do you think it's the best way to go right now?
Kara: Yeah, you must have been eavesdropping on us because we had this conversation yesterday. So she's a 1099 employee. And, you know, I asked her, like, listen, most people going into private practice, coming in for a reason, same reason I did. Do you have ambition to want to be an actual partner? You know, I guess technically she would be an associate or a contractor at this point. And she, of her, you know, own volition, is like, that's actually not interesting to me. I love the work we're doing here. I love that I don't have to be in charge. And I love that I don't have to be part of a big corporate system. So this is the perfect fit. I just want to do 1099 work. So I pay her by the hour. There's a bonus structure if she increased her hours. and collections.
But that's what works for her. And I'm delighted by that because I get to still be the boss. I'm not opposed to hiring a partner. If we chose to do that, I would need some strategy around that. But I haven't had to cross that bridge. We are absolutely not competing. I think when you have a strong brand and a very strong referral network, I mean, we are packed 100% full and we've got 200 patients on the wait list. Like there's not an absence of demand for the things that we're doing.
And I think that's a lot to do with you know exactly like I said our brand and the services that we offer so I could hire another person full-time today if I found the right person my initial plan this year was really to build the center of excellence that like had all of the different components of things that we do therapy dietetics physical therapy you know other ancillary service lines and really build out a center and interestingly you know for a And for a variety of reasons, frankly, I went through a health scare earlier in the year and my oldest is graduating from high school. And I was like, you know what, like, I can just pull that lever down a little bit downshift and like, we can just keep seeing patients. And for me, this ability to flex the business according to like what I need in a given season, I have found to be, hugely empowering. So our current plan is keep seeing patients and take good care of them. And then if we want to upregulate, we can do that. We joke, not joke, that we could work anywhere in the world because we're outside of the insurance network and we have the capacity for telemedicine. So who knows? Maybe one of us will move overseas and then you'll see us doing telemedicine from abroad. I don't know, but the ability to change at any given time for me is everything. It feels great.
John: I was going to ask this way earlier and I forgot. You know, it's kind of like, what's the definition of a micro practice? But I guess what I'm asking is in someone who's doing what you're doing, what would be the ideal size for you or for someone else, depending on their circumstances? I mean, what does that mean? You know, most of us can have three to 5,000 patients if we're in an HMO or something where we're trying to churn through, you know, nine to five, whatever. So this is obviously extremely less than that. So what's your vision of that
Kara: Yeah when I did the original math um as I opened the practice my anticipatory practice size was going to be about 500 patients that would give me the end time I wanted with overhead etc and, I haven't looked at my numbers recently. The last time I checked, I was at 650. So I'm a little larger than that. And I feel it. I am full fold. Like I really can't bring on anyone else. So I think I was probably right in the 500s. And I think it depends on what your ambition is. And if I wanted to run a business more than practice medicine, it would be very logical for me to say, I'm going to hire a team of people to bring in revenue, buy out my time, and be able to do more teaching, research, nothing, whatever I want to do. And I guess theoretically I could do that. That may be the long range plan. But I also really value my freedom that I could walk away at any moment, that it could feel like a practice that was very easy to close. And that says more about me than it does about the practice of medicine. But I think for now, we're going to keep it where we are. And maybe next year will be the year that I build the Center of Excellence. We'll see. What is the definition of a solo practice? It's a micro practice. It's not just the number of patients. I think it's the size because once you start scaling, it's just a different set of problems to solve. And I've enjoyed efficiently solving the ones at this stage. There's bigger problems to solve if I start adding people.
John: Well, on the DPZ side, what I've heard, you know, is that it could be 300 to 500 is typical, but it's kind of a certain model that has certain boundaries, certain expectations. And you're doing something which is really more flexible in the sense that it can go in a lot of different ways. So we're going to run out of time here very soon, if we're not already. But let me ask you this. So I know you help people learn how to do this themselves. You've got, I think, some four videos. But really, you have a micropractice mastermind. So tell us about how you do that.
Kara: Yeah, the coaching line of the business really has evolved to help physicians and kind of meet them where they are. Some people are just like, listen, I want to pick your brain for an hour. Fine. I'm happy to sit down and meet with people and do one-on-one coaching in that way. But truly, you know, medicine is a team sport and I don't pretend to know all the answers. I think it's fascinating to have a group of a dozen to 20 people who are sitting in the same space every Wednesday and working through the same problems, which, you know, imposter syndrome and perfectionism still continues to show up in your business.
I have a long joke, like, if you want to do a lot of personal growth, you should open a medical practice because your scarcity will show up, your control issues will show up, all of that. It will definitely unveil things that are there. And so being in community with people who are equally as optimistic and freaked out or ambitious and also like running into their own stuff, I think is wildly empowering. And it's exactly what I needed when I was starting. I wanted to be in a community of people who are doing the same type of work. So that's where my practice mastermind got born. And so we meet every Wednesday. There's basically a six-month curriculum, but basically it's a longitudinal community for people who are launching. We have people who it's just a twinkle in their eye. They have not even told their employer they're leaving. And there's people who have already launched and are working on scaling issues and staffing issues. So it's really meant to support people in those early days. In terms of resources, I too have a podcast. It's called It's Not Just You. So it's literally the pragmatics of building a practice. Come listen to it. I have a YouTube channel. You can follow me on social media. But there's a great blog and weekly email service that goes through pointers about this stuff. So you can find all of that on my website.
John: And I will put links in the show notes so they know where to find you. So that is very helpful. That's what I love. I love guests who have shared what they've done, but also, you know, if they have resources, it makes it very straightforward to help the listeners.
Kara: Absolutely.
John: And so I advise if they have any, you know, some of them are probably thinking, I can never do that, you know, but really just look at what you've got posted already, listen of the podcast and maybe they just can get a little bit more of an encouragement to do something if they're not happy.
Kara: Listen, like if you can do a crash C-section or manage a 750 gram baby or like replace someone's joint, like you can figure out how to learn a business. This is not that deep. It is not that hard. It's different. It's a learned skill, but it is nothing as hard as what you've already done. So you could do it.
John: Any last thoughts before I let you go as far as where medicine's going or what the future looks like for us all?
Kara: I thought we were closing out. That's a huge one. You know, I hope for the best prepare for the worst kind of person. I am eternally amazed by our colleagues' ingenuity and desire to make things work, right? Like no one's coming to save us. We get to save us. And to watch our colleagues say, I'm going to do it differently is just incredible to me. I am equally worried, as many people are about the future in healthcare. And I really do think that we can no longer be passive in our roles and trying to figure out how to provide care for patients. I mean, Lord knows I need people to take care of me and my family as we age as well. So I try to cling to that hope because I hope that our colleagues will be the calvary that we are waiting for.
John: All right, Kara, words of wisdom, and I really want to thank you for being here today. It's been, I've learned a lot, and I think my listeners are going to get a lot out of it. So with that, I guess I'll just say goodbye.
Kara: Thank you for your time.
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TRANSCRIPT EPISODE 454
How to Thrive in a Micropractice
Interview with Dr. Kara Pepper
John: Today's guest was a traditional employed internal medicine physician who, for probably reasons similar to many of us, decided to leave her practice in 2022. Now, before she left, she did become an executive coach, so we're going to talk a little bit about that as well. But the main thing I'm interested in today is to hear about what she transitioned into. So she's been running what she calls a micro practice. It has different features to it that are very interesting. and she also helps other physicians to do what she has done. So, Dr. Kara Pepper, welcome to the PNC Podcast.
Kara: Thanks for having me. I really love what you're doing to support physicians. There's never been a better time than that.
John: Yes. I thought maybe when I started this, you know, things would get better, but I don't know. There seems to be more and more incentive to change. However, at the same time, there's a lot more resources out there for physicians who are looking to maybe shift one way or another. And you've got some things that we can talk about. But first, we have to talk about your story, about how you became a physician, and then why you ended up leaving your initial practice. So why don't you give us the, well, the medium version of that lengthwise.
Kara: The medium version. Sounds good. Well, you know, I grew up wanting to be a professional ballet dancer. I never thought I would go to college. And I left home in eighth grade to train to be a ballet dancer in Russia. And came back and went to like a boarding school for ballet dancers and then got a job. But it was amazing. But because of eating disorder-related injuries, I kept getting injured and I could not keep dancing. And because I was a patient of physical therapy for a long time, I thought, well, maybe I'll go to PT school. And my orthopedist said, I think your personality is better suited for medicine. So I applied to med school. That is the extent of what I knew about med school. I had no doctor mentors. I had no idea what I was getting myself into. But as it turns out, dancers and doctors are the same people. You know, we show up at work every day trying to get a little bit better at what we do. We learn the technical aspects, but really it's like the art of application.
Everyone applies things a little differently there's lots of perfectionism lots of workaholism so it was really easy transfer. I looked good on paper in many ways in med school and residency and in my early practice, thought I wanted to be a teacher but also really value autonomy, so I ended up in private practice. And it was the right place for me at 30, but it really did not end up being the right place for me by 45. I wanted to be able to fix problems. I wanted to be able to pivot easily without a big bureaucratic system. I wanted to shift my practice as my interest grew and I evolved as a person. And I had opened the telemedicine line for our big 70 physician multi-specialty practice, and then COVID happened. And all of a sudden, we were all home doing telemedicine, as everyone here knows. And I was like, this is the best medicine of my entire career. I actually have time, I can talk to patients, I can put together the pieces of the puzzle without feeling eternally rushed. And in the background of all that, I became a coach really as a product of my own burnout. I wanted another skill to try to help patients, but physicians kept coming to me like I had the answers to some problems. And so I built this coaching practice kind of unexpectedly and ultimately had to take my own advice, which was, listen, like, life is short. You could be dead showing up at work next week in this pandemic. And even though it looks good on paper, it's not what felt good anymore. I, you know, my kids were growing up, my parents were aging, and I wanted to have a life that I didn't regret. And so I left and started my own telemedicine practice.
And the big caveat with that was that I had to start a telemedicine practice because of my non-compete. There was a big limitation. And so it was the way that I wrote out my non-compete for two years. Started an eating disorder practice, which very rapidly evolved into this MCAS-POTS-Ehlers-Danlos practice. And after two years, I went back in person, which is where I'm broadcasting from right now in my 150-square-foot office space.
John: Nice.
Kara: Yeah, it's great. And so when I say I have a micro practice, I truly mean that. It is a very small footprint with a very low overhead. But in 4 years, it's grown to 17 states. I've hired another doc. We have a team that's entirely virtual that supports us. And so it's a way for us to be able to practice medicine on our own terms in a way that's healing for us and takes care of the patients we really love taking care of. That's what got me here, and there's lots more to say about that, but it's a world that I've created that allows me to love medicine again and feel like I'm in charge of my own destiny and can practice the way that I want to, which is really part of my core values. So, it's fun.
John: It's a nice story, although maybe the part where you weren't feeling well for too long is not, but it's so common for physicians.
Kara: That's right.
John: I think my mentor was Dr. Kildare or one of those guys on TV. I had no mentors. I had no one in my family either. I kind of relate to a lot of things you said, and a lot of the people I've worked with over the years just got burned out, basically, moral injury, whatever you want to call it. And, no, it's great that, you know, you took the bull by the horns and then said, okay, I'm going to do something that really aligns with what I want to do and what my vision and mission in life are. Okay, so we get that you left the old and you started this new and you took advantage of the telemedicine, which is awesome. So what does your practice look like now in a little more detail? What is it like every day? You know, what does that mean?
Kara: Yeah, so I had done this coaching exercise when I was burning out like back in 2016, 2017. And someone said like, just like, wipe the slate clean. What is a perfect day for you to feel like? What's the pace? What will you not be doing? You know, who are you with, etc. And I like very kind of like secretly wrote out this plan of like, I want to wake up and not chart first thing in the morning. I don't want to pre-chart before I show up at work. I want to drink hot coffee before it gets cold. I don't want to feel rushed. I want to work out. and then I want to start my day and I want to sit down and actually eat lunch and have a chance for my brain to recoup before I start the afternoon and then I want time afterwards. And I was like, that's not possible. I mean, that's just not how medicine is built. And the truth is, that is literally what my day is like now. I wake up, I have to get my kids on the bus and then I work out and I show up at work. My first patient's at 9 to 10, depending on the day. I see patients basically 9 to 12 and then 1 to 4. So I take a full hour in the day for lunch and administrative work.
And yeah, I have some business of medicine stuff that I have to do after that. But, you know, I've created a life that feels good and I can see patients in that window of time. My business model is outside the insurance industry. So it's a pay-as-you-go model. So it's not a retainer. It's not a subscription. I'm not a DPC doc. It's like therapy. It's like Amazon. You know, you pay and then that's it. And for me and the patients that I take care of, that's the best business model in terms of the arc of the patient experience.
And for those reasons, I really like it. But I think culturally, it's kind of ends up in the DPC world, even though it's not formally a DPC practice. And, you know, the coaching part that I had done for a while, supporting physicians through career change, you know, it went from talking about burnout and perfectionism and imposter syndrome, really to people saying like, I want to do what you're doing. You know, how can you just, can I just have 30 minutes of your time to like sit and pick your brain? And I realized that so many physicians are, even though we're seeing all of private equity and venture capital buying up private practices, so many physicians are saying, that's not working for me. I want to be able to take care of patients the way that they deserve, the way that I deserve.
And for a long time, we've seen that happen in the DPC space. But now we're seeing this real expansion for specialists, especially proceduralists, who are, whether or not they're taking insurance or not, who are stepping off and saying, I can do it better. I don't have to have this massive administrative overhead. I can leverage technology. I can leverage resources and shared resources, even fractional CFOs, where people are saying, I can do this in a lean budget model so that I can practice the way medicine was meant to practice. And so it feels really, really good to be able to support people who need a road map in that way.
And I'll tell you, I've made many mistakes. My husband's not in medicine. He's an MBA. And so when I quit my job and said, hey, I'm going to start this practice, he was like, what's your business plan? And I was like, the plan is that I'm going to make money and see patients. And he was like, oh, my God, that is not a plan. That is WISHFUL thinking. And so I certainly didn't know what I was doing. And there was a lot of bootstrapping. But that is not necessary now. There are so many Facebook groups, conferences, micro-practice masterminds like mine, but like business communities for physicians saying like, you don't have to reinvent the wheel. You can have this roadmap that's laid out for you if this is what you want. And to be clear, private practice ownership's not for everyone. Like some people just want to be a worker bee. They want to show up. They don't want to have to deal with HR issues and things like that. That's perfectly fine. But for those of us who value autonomy and really want to do it different,
You just get to choose your heart. Do you want the heart of not being able to make the decisions or do you want the heart of being able to make decisions? And I think we kind of fall into one of those two categories.
John: You know, I have a lot of questions just based on what you said already. I'm going to go way back to the beginning of when we started this because this comes up a lot when I talk to other physicians who are thinking about doing something. Did you, when you were thinking, okay, I'm reaching the end of my rope, did you in your mind know you had a non-compete, knew the specifics of it, or was that like something where it was like a rude awakening at the last minute that, oh my gosh, I forgot, I can't really go so much?
Kara: Oh, no, I was well aware. And, you know, whenever you're making a big change, you know, there has to be enough incentivizing energy to get over the discomfort of change. And so every day I'd come home and be like, you know, to my husband, yeah, I'm so burned out. I don't want to do this anymore. He would be like, but the non-compete, but the pension. I got a pension, still have, I guess, a pension through my previous job, right? Like, they really were trying to keep us there in those systems. And so we would point to these things and say, well, I guess, you know, those feel too big to get over. I might as well just stay here until I had done enough personal work and had enough clarity to be like, this is actually not enough to keep me anymore. So, yes, I knew about the non-compete. And telemedicine still then, even though it was 2022, was still, the laws were still evolving around that. And quite frankly, my hospital system that owned my practice was like, try us. We would love to take you to court so that we can set the precedent for the state of Georgia. They were very kind of unabashed about that. And I think that is a real disincentive for people who are nervous about managing their non-competes. And anyone who says, oh, they'll not enforce it, I assure you, in the state of Georgia, at least, they are happy to try to set those laws. And so the telemedicine arm was the way to kind of navigate around that and allow me to still preface medicine, even if I didn't want to drive 20 miles away from my house.
John: Do you think they put a clause in their contract that says, well, you can't do telemedicine from home either? I mean, they do. Yes.
Kara: In fact, that is exactly what they did. They're, because Georgia is a pro-business state, what they said, the sentiment of a non-compete is to protect the business. So they said, any human who lives in your non-compete territory, even if you have no relationship with them, they are off limits. If they live within that non-compete area, even if they've never been seen by our hospital system, they are off limits because that is our territory. And so, ironically, I could have driven 20 miles, parked myself in front of their sister hospital, you know, another community hospital owned by the same system, and practiced there, but I couldn't see a telemedicine patient that never had a relationship. So, I mean, medicine is a business, and so hospital systems and private equity are absolutely trying to protect their revenue. And so, there's many ways around that, but that's how I did it. It's just like I'm going to do telemedicine outside of that territory.
John: That works because you're licensed in several states, correct?
Kara: Yes, 17 states.
John: 17 states. When you started the telemedicine, well, are you still doing that now a little bit?
Kara: Yes. Yeah, so it's a hybrid practice. So as I spent two years doing telemedicine, I got a reputation for the type of work that I was doing. I have referral networks in most of those states, and so they would send me patients. And so when I went back in person, I do think there is a deep desire for patients to be seen in person. They want the human connection. They want the healing touch. They want you to lay hands on them, even if for many of us, we don't, you know, our brain is our primary tool, not necessarily our brain and our hands. Anyway, and so I do a hybrid model where I show up in the office, I'm sitting in this chair either way. And some patients I see by telemedicine, some people walk through the front door. And it allows people to kind of choose what's right for them. And there's a lot to be said about how people make that decision. Yeah.
John: So you kind of talked about how your day looks, how many days a week you're working and like, what are the total number of hours you'd have to be available on the weekends? What does that look like?
Kara: Yeah, so call is a really interesting question. If you take insurance, that is often part of the insurance contract that you are required to have 24-hour coverage for your practice. Because I don't, I do not have 24-hour coverage for my practice. That was revolutionary for me.
I think for many people, they worry, like, I can't go into private practice because I don't want to be on call all the time. I don't want to be on call all the time. And as I went into a call for many years for a practice where I was covering 100,000 patients when I was on call, there is nothing I can do from home at two in the morning as an internist. I either need to send them to the emergency room or I need to say, listen, this is something that can wait until the morning. And I really felt strongly that medicine is a team-based approach. And if you're calling me in my solo practice, I'm not going to be coming in at two in the morning. So I don't take call. My business hours are nine to four. Those are the hours that I'm available. Outside of that, if there's emergencies, I will do my best to do that. Now that I have a doc who's joined the practice, we will share vacation coverage. But in the very early days when the practice was 50 patients, I'd say, listen, I'm going on vacation next week. Send me all your med refills. Send me all your paperwork. I will do my best yet at taking care of. And I'll see you when I get back. And I do think patients really appreciated being treated like a part of this community. Like, okay, great. She's a normal human. That's part of why we like going to this practice. But as the practice has grown, you know, of course, people have expectations, especially because they're paying cash to see me. But we still do communicate in that way, like this is when we're available and this is when we're not. So I see patients five days a week, nine to four, and that's it.
John: Well, I've been associated with urgent care for about 10 or 11 years. I'm not practicing now, but it always kind of struck me as, you know, we're here, we're seeing some pretty sick patients and we don't send them all to the hospital, but we don't have night coverage or weekend coverage either. You know, it's just like, it's just the nature of the beast and, uh, go to the ER if something changes and I guess that's all you can do. The nature of the patients that you see, is it skewed, you know, based on your interests and just word of mouth, would you say? Or is it a full kind of internal medicine breadth of conditions, would you say?
Kara: Yeah, I would say that it's evolved in the past four years. You know, I will be a primary care doc in my bones until I retire. But what I have recognized, I still do have primary care patients who follow me for my old practice, but really the sweet spot for us, I open to really serve adults with eating disorders and no one ever just has an eating disorder. They often have this very predictable pattern of comorbidities. And so this triad, which many docs are not familiar with, really is a big part of the eating disorder community. And so that's where our reputation evolved. And I do think that's really the mission of this practice right now is to serve this subset of internal medicine diagnostics. It's really an invisible illness clinic, but we're doing a lot of diagnostic testing and helping people figure out a unique plan forward. And even though I'm in Atlanta, a city of six and a half million people, it is wild to me that I am the only person in my partner doing this type of work. And so I really do think that's the mission of the practice for us to be able to focus on that. And so my partner does not see any, you know, if someone showed up on her schedule for a physical, she'd be like, let me just refer you out before you even walk in the door.
Because that's not what she does. But I still love my folks that I've seen for like 15, 20 years. And so I'll still see them because they're easy enough at this point in time. But I think, you know, like I mentioned, my husband's not in medicine. And when he graduated with his MBA at 27, if he was still in the same job that he had then, people would think there was something wrong with him. They were like, do you not have any ambition or desire to change or have you not learned anything in the past 20 years? And I think this fallacy, like when I interviewed out of residency, I said, we want to hire you and retire you. And I didn't understand it at the time, but I had this like bone deep kind of dread, like, oh my God, I've got to do the same thing every day for 30 years. It feels terrible, even in internal medicine, it's so broad. And so I have really appreciated the ability to augment my career over time, but particularly even in solo practice to be like, I think this is what I like doing. But over time, I'm allowed to say this is what we're doing now. And that for me has really kept me engaged with the work that we're doing. And I'm having the most fun I've ever had in my career. It's really, really interesting medicine.
John: I'm going to ask you, did you talk about this before you did it with other people, other physicians? Because I've talked around here, you know, about not me personally, but like saying, well, why don't you consider DPC? Or why don't you consider, you know, just private practice, you know, self-pay, whatever. And they're always like, there's not enough people around here that would be interested in that. Now, we are outside of Chicago. We're like an hour south. So we are in a little bit of a semi-rural area, but you're near Atlanta or in Atlanta. So did people sort of try to have you not do it, you know, discourage you, or did it take very long to build? What does that look like in the marketing and so forth?
Kara: Yeah, I think there's always going to be people who dissent because it feels scary to them. And by breaking the status quo, it makes people around you question, like, Maybe I could do that, or maybe I'm too scared to do that. So often, some of the feedback I got was like, oh, no, this is impossible. It's clearly not. That being said, you have to know your community that you're working in. What is the culture there? What is the price point there? You know, there's concierge medicine docs in Atlanta who charge $10,000 a year. Would that work in a very rural area with low levels of income? No, of course not, right? So there is a piece of market research where you need to understand your competition, what the culture is, what the general financial income of the communities are. But regardless of where you set your price points, there's a lot to be said that we talked about in the Mastermind about advertising.
But medicine is still very much a trust-based, relationship-based referral system. Everyone who's listening to your call knows when they themselves either have a problem or they're advocating on behalf of the patient, They'll ask, like, who do you know? Who should I send this person to? You know, they understand someone's brand. And so I've done...
I will say virtually zero. I've done one paid advertisement in four years, but otherwise zero paid advertising. It is 100% bent based on me making time because in the early days of my practice.
My schedule wasn't 100% full. So every day I was doing marketing, I would sit down with dieticians, therapists, other doctors and say, this is what I'm doing. Let's collaborate and building those trust-filled relationships. And one of the most fun things that I've done in the past four years is like kind of go back to med school. Like because I had, you know, a half day or a day where I wouldn't have had patients in the beginning, I went and shadowed people. And it was fascinating to me to like, one, build these relationships, but also like learn from our colleagues, teach them about what I do.
And I think at the core of it, we're all still kind of nerdy. We still like, if you're still practicing, you still like medicine and want to learn some stuff. And so it's been really fun to build these very professional relationships. And out of that, even in solo practice, I've published independent research, I've written papers, I have blogs, I've spoken nationally at all kinds of conferences on both medical and physician burnout stuff. And so to create this portfolio career that feels really engaging, it is like having an academic career, but I'm in solo practice. And it's just really interesting. So I think that's the take-home message. Like you get to figure out who you are at this stage in your life and what you want to do and do it by choice. That may mean stay employed. Okay, great. You want to stay employed because you don't want to disrupt your family and move your kids out of their schools? Fine. Just like understand that you're doing that by choice and taking the hits that come with that.
You want to start a private practice? Awesome. You're going to have to learn some new skills that you've never done before and that's okay. But there's no right choice, but you have the power. Like none of us are stuck. We all get to choose by choice what we do moving forward. And I think that's pretty cool.
John: So now, do you have any staff other than your new partner?
Kara: Mm-hmm. Okay, so I have a number of folks started with... So I hired a team of virtual assistants in the very beginning because I was leaving my old practice a new one. So I was like, I just need people to help me, like, set up the systems and integrate them. Like, I just literally need someone to answer the phone. So I hired temporary virtual assistants, and then once I got up and running, I let them go. And it was literally just me, no one else, for about two years. And that worked until the practice really was very busy. And that's not reasonable for me to answer the phones anymore. I would argue that by the time physicians think they need help, they've needed help for a long time. So my advice is hire someone much earlier than I did. That's another story. And so my first big employee, I hired a woman who was kind of a jack-of-all-trades person. I said, listen, this whole business lives in my brain. I need it to be out in the form of like protocols, employee handbooks. You know, if we're going to hire someone, we need an actual onboarding program. So you can think of her as like an office manager, an operations specialist. So she manages my inbox, she interviews people, she does research for me, she does my blog, she, you know, she kind of like runs the administration part of things. I then hired a nurse who was the patient-facing person, and she was answering phones for a while. But she now is doing a lot of prior auths, paperwork, calling with lab reports, clinical, you need a nurse brain stuff.
And now we have a full-time virtual assistant who's in the Philippines, and she's our phone person. So she's doing scheduling, answering phones, doing some communication stuff, basically like a medical VA, if you will. So it's been really interesting. One, I get to choose people who are the best fit, no matter where they are in the world. They don't have to be here in Atlanta. And also, it's a way to keep the overhead down. It's much, much cheaper to hire someone overseas than it is to hire someone who needs benefits and is sitting here. And so as the practice grows, I think the next most obvious person for us to hire is that we actually will finally need someone in person if we want to expand our service line, especially if we hire a third doc. So getting an in-person MA. And I think that for me is one, kept the overhead very lean so that we can keep prices down and still make a decent income. But it allows us to kind of think strategically about what our next hire is and how to create the right role for our practice that may not have a typical job description in a corporate setting.
John: You did bring on a partner, an associate, what have you, to go, you know, it's like 100% increase in staff kind of thing.
Kara: Yeah, that's right. That's right.
John: Providers, although it sounds like what they're doing is a lot different than what you're doing and not really mimicking what you're doing exactly. But what is your thought about that? It's difficult sometimes to share. It's, you know, do you see this, is this person going to be an employee or is an employee? Will stay that way? Are you looking at partners? What are you thinking about how that's going to continue to grow, and how do you think it's the best way to go right now?
Kara: Yeah, you must have been eavesdropping on us because we had this conversation yesterday. So she's a 1099 employee. And, you know, I asked her, like, listen, most people going into private practice, coming in for a reason, same reason I did. Do you have ambition to want to be an actual partner? You know, I guess technically she would be an associate or a contractor at this point. And she, of her, you know, own volition, is like, that's actually not interesting to me. I love the work we're doing here. I love that I don't have to be in charge. And I love that I don't have to be part of a big corporate system. So this is the perfect fit. I just want to do 1099 work. So I pay her by the hour. There's a bonus structure if she increased her hours. and collections.
But that's what works for her. And I'm delighted by that because I get to still be the boss. I'm not opposed to hiring a partner. If we chose to do that, I would need some strategy around that. But I haven't had to cross that bridge. We are absolutely not competing. I think when you have a strong brand and a very strong referral network, I mean, we are packed 100% full and we've got 200 patients on the wait list. Like there's not an absence of demand for the things that we're doing.
And I think that's a lot to do with you know exactly like I said our brand and the services that we offer so I could hire another person full-time today if I found the right person my initial plan this year was really to build the center of excellence that like had all of the different components of things that we do therapy dietetics physical therapy you know other ancillary service lines and really build out a center and interestingly you know for a And for a variety of reasons, frankly, I went through a health scare earlier in the year and my oldest is graduating from high school. And I was like, you know what, like, I can just pull that lever down a little bit downshift and like, we can just keep seeing patients. And for me, this ability to flex the business according to like what I need in a given season, I have found to be, hugely empowering. So our current plan is keep seeing patients and take good care of them. And then if we want to upregulate, we can do that. We joke, not joke, that we could work anywhere in the world because we're outside of the insurance network and we have the capacity for telemedicine. So who knows? Maybe one of us will move overseas and then you'll see us doing telemedicine from abroad. I don't know, but the ability to change at any given time for me is everything. It feels great.
John: I was going to ask this way earlier and I forgot. You know, it's kind of like, what's the definition of a micro practice? But I guess what I'm asking is in someone who's doing what you're doing, what would be the ideal size for you or for someone else, depending on their circumstances? I mean, what does that mean? You know, most of us can have three to 5,000 patients if we're in an HMO or something where we're trying to churn through, you know, nine to five, whatever. So this is obviously extremely less than that. So what's your vision of that
Kara: Yeah when I did the original math um as I opened the practice my anticipatory practice size was going to be about 500 patients that would give me the end time I wanted with overhead etc and, I haven't looked at my numbers recently. The last time I checked, I was at 650. So I'm a little larger than that. And I feel it. I am full fold. Like I really can't bring on anyone else. So I think I was probably right in the 500s. And I think it depends on what your ambition is. And if I wanted to run a business more than practice medicine, it would be very logical for me to say, I'm going to hire a team of people to bring in revenue, buy out my time, and be able to do more teaching, research, nothing, whatever I want to do. And I guess theoretically I could do that. That may be the long range plan. But I also really value my freedom that I could walk away at any moment, that it could feel like a practice that was very easy to close. And that says more about me than it does about the practice of medicine. But I think for now, we're going to keep it where we are. And maybe next year will be the year that I build the Center of Excellence. We'll see. What is the definition of a solo practice? It's a micro practice. It's not just the number of patients. I think it's the size because once you start scaling, it's just a different set of problems to solve. And I've enjoyed efficiently solving the ones at this stage. There's bigger problems to solve if I start adding people.
John: Well, on the DPZ side, what I've heard, you know, is that it could be 300 to 500 is typical, but it's kind of a certain model that has certain boundaries, certain expectations. And you're doing something which is really more flexible in the sense that it can go in a lot of different ways. So we're going to run out of time here very soon, if we're not already. But let me ask you this. So I know you help people learn how to do this themselves. You've got, I think, some four videos. But really, you have a micropractice mastermind. So tell us about how you do that.
Kara: Yeah, the coaching line of the business really has evolved to help physicians and kind of meet them where they are. Some people are just like, listen, I want to pick your brain for an hour. Fine. I'm happy to sit down and meet with people and do one-on-one coaching in that way. But truly, you know, medicine is a team sport and I don't pretend to know all the answers. I think it's fascinating to have a group of a dozen to 20 people who are sitting in the same space every Wednesday and working through the same problems, which, you know, imposter syndrome and perfectionism still continues to show up in your business.
I have a long joke, like, if you want to do a lot of personal growth, you should open a medical practice because your scarcity will show up, your control issues will show up, all of that. It will definitely unveil things that are there. And so being in community with people who are equally as optimistic and freaked out or ambitious and also like running into their own stuff, I think is wildly empowering. And it's exactly what I needed when I was starting. I wanted to be in a community of people who are doing the same type of work. So that's where my practice mastermind got born. And so we meet every Wednesday. There's basically a six-month curriculum, but basically it's a longitudinal community for people who are launching. We have people who it's just a twinkle in their eye. They have not even told their employer they're leaving. And there's people who have already launched and are working on scaling issues and staffing issues. So it's really meant to support people in those early days. In terms of resources, I too have a podcast. It's called It's Not Just You. So it's literally the pragmatics of building a practice. Come listen to it. I have a YouTube channel. You can follow me on social media. But there's a great blog and weekly email service that goes through pointers about this stuff. So you can find all of that on my website.
John: And I will put links in the show notes so they know where to find you. So that is very helpful. That's what I love. I love guests who have shared what they've done, but also, you know, if they have resources, it makes it very straightforward to help the listeners.
Kara: Absolutely.
John: And so I advise if they have any, you know, some of them are probably thinking, I can never do that, you know, but really just look at what you've got posted already, listen of the podcast and maybe they just can get a little bit more of an encouragement to do something if they're not happy.
Kara: Listen, like if you can do a crash C-section or manage a 750 gram baby or like replace someone's joint, like you can figure out how to learn a business. This is not that deep. It is not that hard. It's different. It's a learned skill, but it is nothing as hard as what you've already done. So you could do it.
John: Any last thoughts before I let you go as far as where medicine's going or what the future looks like for us all?
Kara: I thought we were closing out. That's a huge one. You know, I hope for the best prepare for the worst kind of person. I am eternally amazed by our colleagues' ingenuity and desire to make things work, right? Like no one's coming to save us. We get to save us. And to watch our colleagues say, I'm going to do it differently is just incredible to me. I am equally worried, as many people are about the future in healthcare. And I really do think that we can no longer be passive in our roles and trying to figure out how to provide care for patients. I mean, Lord knows I need people to take care of me and my family as we age as well. So I try to cling to that hope because I hope that our colleagues will be the calvary that we are waiting for.
John: All right, Kara, words of wisdom, and I really want to thank you for being here today. It's been, I've learned a lot, and I think my listeners are going to get a lot out of it. So with that, I guess I'll just say goodbye.
Kara: Thank you for your time.
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