In this episode of the Finance For Physicians Podcast, Daniel Wrenne talks with Drs. Cady and Ryan Brown about their journey breaking away from traditional primary care to start their own concierge medical practice, Downtown Drs. Brown, located in Lexington, Kentucky.
- Cady and Ryan’s concierge medical practice and career progression
- Primary Care Patient Load: From honeymoon period to fast track to burning out
- PTO Requirements: Physicians not valued as people, professionals in practice
- Reassurance and Education: Patients need to know if things are okay or not
- How and why Cady and Ryan created their practice from scratch
- Tradeoff: More security, less setup work for autonomy, independence, finances
- Competition: Not many concierge medical practices, but demand definitely exists
- Pressures/Stressors: Different now, feels better being in control of own destiny
Full Episode Transcript:
Daniel: What’s up, everyone. Welcome to the finance for physicians podcast. I’m your host, Daniel Wrenne. Join me as we dig into what it looks like for physicians to begin using their finances as a tool to live better lives. You can learn more about our resources at our website. Let’s jump into today’s episode. What’s up guys. I’m excited today to share my recent conversation with Drs. Ryan and Katie Brown. They’re such a great example of people that are really living out their values. So they started in a traditional primary care type of position at a larger hospital. And after a couple of years found that it just really wasn’t checking the boxes for them. But instead of weathering it and just working through it, they decided to make some pretty big changes and ultimately decided to start their own concierge medical practice. It’s called Downtown Doctors Brown, and it’s here in Lexington, Kentucky. And since then, over the past three years, they’ve been building that practice up and now today they have a full patient load with a waiting list, and are, as you’ll tell from our conversation, really just happy in their position. So I think you’ll definitely enjoy hearing our conversation today. So let’s jump into that right now.
Daniel: What’s up guys? How’s it going? This is, Ryan and Katie brown with me today.
Ryan: Hi. Good. How are you?
Daniel: I’m doing well. So I’m super excited to chat today. We’re going to be talking about you guys and your, career progression. I know you started out in-practice in kind of a traditional primary care setup and life has changed quite a bit since then. And, now you have a totally different setup. You have your own, concierge medical practice. I look forward to talking through that transition today. I think it’s been from what I’ve seen an excellent change. So, I appreciate you guys coming on to chat about it.
Cady: Yeah, definitely. We’ll talk all day about it!
Daniel: Yeah. It’s been fun. We’ve talked a lot about it over the years and I guess maybe we could start back when you started in practice. When was that?
Cady: The summer of 2015 is when we finished residency and came back to Lexington. And then we started our own practice three years ago next month, which would be September, 2018.
Daniel: What was that first job like?
Cady: We basically did three years there and then we’re almost exactly three years in our own practice. So it is a good comparison time, I guess I just jumped right in. It was very much what our only option was when we finished residency. We both did internal medicine and an extra chief year, and that was four years and then four years of med school. So during those eight years, it seemed like nationally, especially in Lexington, the trend shifted from primary care docs, owning their own practices to all being owned by bigger hospital systems. It might’ve started earlier in that, but it felt like when I went to med school, there was more options, and the majority of people still owned their own smaller practice. And then when we got done and we were looking for jobs, there were no options, other than going with a bigger employer in one of these little primary care offices they had purchased. And some of them were still stand alone and hadn’t changed much. Many of them consolidated into new buildings. There was a little bit of variety there, but at the end of the day, you were basically going to work with a large employer, in a smaller practice. So that’s what we decided. We decided to come back to Lexington and those were our options. We ended up selecting a practice that had been most recently independently owned. The staff had been there a long time. They knew their patients well. We felt like that’s the kind of primary care we wanted to practice where people invested in their patients and in each other. The hospital owns the practice, but this seems like a good spot. And we started and the staff were great and the patients were great. And you know, we started off with zero patients in the late summer, early fall of 2015. It started off really well. You get to meet your new patients and start to take care of them. You work with the staff.
Ryan: Primary care is what we had each wanted to do. And when you’re establishing those relationships and taking care of people, it feels really good. And then at some point, and I don’t know what the date was, but there just got to be so many patients. Maybe after a year and a half or two years. And each of us have a couple of thousand people that were taken care of and all of a sudden, it doesn’t feel as fun. You don’t have a relationship with your patient. You’re desperately trying to take good care of them. That’s why you went into the profession, but you don’t have time to do it. You don’t have time in the room with a patient. And you’ve got patients to see, reports to review, medicines to order, and all kinds of insurance things to do. And if you take the time with a patient that they deserve, you get behind. Patients are waiting for hours, then they’re mad at you.
Cady: You get home late and then you finally get your head on the bed at night and you’re stressed about what you missed. And if you took good care of everyone or not, and you get up the next morning to do it again, and you’re probably charting before you go to bed at night. So it pretty quickly went from, oh yeah, this primary care thing is great. This is what we had hoped for. To something that felt unenjoyable, unsustainable, and like Ryan often says, on this fast track to burning out.
Daniel: Early on, you had a lower patient load and it sounds like you were able to spend more time with patients and there wasn’t so much pressure to fit everybody in. But that quickly evaporated to a point where the patient load was causing pressure. Was that the primary stressor or were there other factors beyond this, because I can’t imagine dealing with 2000 people in anything. That’s just a lot of people. Was there more to it beyond just the volume?
Ryan: That’s was a good point mentioning during the ramp up there was a honeymoon period where you’re out, you actually have a real paycheck, you dreamed of doing this primary care thing and you don’t go into primary care these days, unless you really want to. The majority of people do not go into primary care. They go to things that are not generalists for the most part. So, you know, we had a passion for it, individually and collectively. So yeah, it did feel really good, but yeah, at some point the volume just reached, a critical mass and it just started to take away from what you’re trying to do. And what was really killing me was having to move faster than what I wanted. And then also not being able to take workups as far as I wanted them to. And I would have to send them to a specialist or maybe start a medicine, when I would rather discuss other option. But just to keep up with the pace you just had to move through quicker than what the traditional workup would allow. It wasn’t like I was not allowed to do these things. But it was keeping me from working at the top of my skillset and was faster than what I wanted to work. I don’t remember when the honeymoon wore off. Essentially we realized a couple of years in this is not sustainable. This is not why I sacrificed for as long as I did and built up student loans and took all these years to do this. This is not primary care the way I want to do it. Now there’s probably some docs out there who their personality really fits that model. And they may do well in that. It’s more of their, you know, nature to work that way. But both of us wanted something different out of it.
Ryan: And I would even say there was probably nothing in the beginning that didn’t feel great, but probably in this middle portion as we started to get busy, I think there were other things about being in a hospital on practice that started to become frustrating. And, they maybe seem little at first, but there were certain ways that the clinic had to operate; how things were ordered, how people scheduled appointments that felt like they were inefficient. But if you made a comment and try to change it, then nothing really happens. So you felt like, with a modest volume of patients and an efficient system, it maybe would have been manageable. And you’re trying to make that happen. And then there are all these layers of administration and it never happens. And you have a monthly meeting and they say, well, just see more patients. And that became pretty frustrating.
Cady: And then feeling valued as people and professionals, we were only given a certain amount of PTO. And one of our kids would have a little program at school. They’re in preschool, it takes 10 minutes and you were required to take a half day of PTO. And you only have pretty limited PTO to begin with. And, you know, you would really like to be able to just come in a half an hour late to work that day and not take some of your vacation time. So it felt like you really kind of weren’t valued for what you were giving to the practice. So much was being asked of you and then you weren’t given much in return.
Ryan: Absolutely. Without a doubt.
Cady: Deeper relationships, you know them better, they know you better, you work harder on these issues together, and then you get the time to actually enjoy the benefits versus just rushing to the next patient, because there’s three in the waiting room.
Cady: And I think that your line of work and ours are also similar in that two of the main things that we do are educate people and reassure them. And those are a huge value to people, but they take time. And so ordering a lab test or a diagnostic procedure, a medicine, sending them to another doctor, those are what we mostly did at the old practice, like what Ryan was saying, because you can do them quickly. But really what people usually need and what they’re so grateful for once you give it to them, is reassurance and education. I just need to know that things are okay or they’re not, and what’s going on. And they really value getting that from us and appreciate it. And the flip side of that is in the old office, people would be so frustrated by how hard it was to get an appointment or the fact that I was running an hour behind, which we spoke about earlier, I’m running an hour behind because I’m trying to take care of the other patients in a way that they deserve. So you would hear these frustrations all the time. And then, the patients have this kind of misunderstanding that I have the power or the ability to change how the clinic works or get them an appointment sooner or make it so they don’t wait. But then as a person who, prides myself on the quality of care that I’m delivering and having patients be satisfied, it was really hard for my personality to hear this, get this negative feedback and criticism all the time and then feel like it was out of my control to make it any better.
Daniel: I think a ton of people can empathize with you or have gone through exactly what you’re describing, but what’s awesome is that you guys did something about it. And you did it pretty fast. Do you remember exactly when the wheels started turning, like I gotta make a change and I need to do it fast. Or what was that like?
Ryan: I was more miserable quicker, and it quickens my pulse even thinking back to then because it is extremely anxiety provoking. But I almost feel like I didn’t have a choice which I think helped kind of pull the rip cord and make the change because being on that fast track to burnout so fast out of the gate and after sacrificing for so long, and I’m a little bit older, I didn’t go straight through to med school, you know. So it was just like, what in the world. We put all this effort and time and, went into a passion project with primary care essentially and this is not sustainable. That was around 18 months or two years into practice. And that was where it was like, okay, we kind of signed our initial three-year contracts. We weren’t like in a lock-in, but it was like, okay, well we had kind of an end date with that to renew a contract. So about a year out from that, we started looking into other options. Like what can we do here? Because this is not what I want it to be. And to be honest, I did not know anything really about concierge medicine. I’d heard the term here and there. It certainly wasn’t something we were trained about in residency or had any discussions with anybody. But fortunately we were in a position where there was a physician near us physically, practicing that with a national group who does concierge. So I could literally see how a different way looked. And that was just lucky on our end to not only kind of learn about the concept, but be able to have a physician who was doing it near us. And then we eventually talked to him and kind of picked his brain about what he was doing.
Cady: So that really opened my eyes and then our eyes up to the idea this model could be the antidote to these ills we just talked about and were feeling early on in the practice. And, and I do want to say specifically that the higher ups at that practice, we’re really kind to us. The staff were really great and we loved them and we were sad to leave. It really was just the model. And it was just that turn and burn high volume model. Like I think the pieces around us were about as good as they could be, but that model was not going to jive with my personality and how I like to take care of patients. So essentially two years in we discovered this other doc doing a concierge model with a national group and then we began thinking that if we could get ourselves in that position, we could practice medicine like we want, we could still pay our bills and it would be more at a 20 or 25 year career pace, versus what I’m on right now, which is like Googling, what do you do with an MD other than something like this. So that’s when we kind of put our heads together and started exploring.
Daniel: So about two years in the wheels started turning and you happened to be in close proximity to this physician that was actually already practicing concierge medicine. Except for, they were kind of further down their career path. Right?
Ryan: You’re right. It’s really early. And in fact, what we did out of the gate was… There are three or four big national companies who kind of partner with docs to help them create a concierge practice out of their already full, robust practice. Often in the last five or 10 years of their career is where this is kind of becoming more common and it’s almost like they’ll come in and make it turnkey and essentially carve out X number of patients from your huge panel. And that’s the model that was most common three or four years ago when we were looking into it. So when we first learned about it and reached out to two or three of these national companies to feel them out and learn about it, and Cady can speak more on this because she had a few more of the conversations, but they really didn’t have much interest in us because we were too early out. They felt like you needed to be at least 8 to 10 years out from retirement. So it was kind of funny at first. When they finally returned our calls they weren’t interested. They were basically like call us in a few years. But we started doing more research and it was like, hold on a second. You can do this from scratch. That’s basically what we were going to have to do.
Cady: The humor only comes with hindsight and at the time. Ryan had this idea. I found any book I could on direct primary care, concierge medicine, read them, started contacting these places. And they basically told us, yeah, you know, it is a really great practice model. You need to have a longer established relationship with your patients for them to be willing to come over to our practice where they pay to see you. You just haven’t known these people long enough. This is what folks do before they transitioned to retirement. It was scary and disappointing, but I do think it has often been to our benefit that we’ve pursued this together because whenever one of us would start to feel too anxious or worried about the reality of making the transition, the other one would say, but look at what we’re living right now. Is this sustainable? No, it’s not. And we kind of go back on course towards transitioning.
Ryan: Not only was it an advantage to get us, to make the tough call so early on and take the gamble with the huge student loans and all that stuff. It helped push us along when one of us questioned the change. And then when we started, I think it helped a lot to have two of us out of the gate. But when we got those tepid responses from these national groups, it did kind of almost light a fire under us. It was like, we’ll show you. guys. And sure enough, we did.
Ryan: I can specifically remember the guy quoting to me the success rate of a new business at three years, which will be next month. And then it was low. It was kind of almost a scare tactic because once they realize like, oh, okay, hold on. These guys are serious about it. We kept calling. And they looked at the Lexington market and looked at us as a couple and then began to realize, maybe this is not their normal playbook, but it could work. Well, luckily by then we had done enough research to realize you don’t necessarily have to partner with a national group. I think there are huge advantages to that for sure. And I wouldn’t advise somebody not to do that if that works for them, but it gave us enough space to realize like, okay, a lot of these steps are super intimidating but can be done. And then we also found a consultant who kind of helps focus on getting you up and running and cutting you loose, almost like the teach a man to fish philosophy, versus these other national groups where they just like partner with you lock-step in perpetuity forever.
Ryan: And I think if you are in the last 10 years of your career, then sure. Why not? Student loans are paid off by then, and you’re in a different phase of life. They make it turnkey and they take a cut and everything’s better than what they were doing. It makes perfect sense. But for us, we’re looking literally at a 20 or 25 year career. And it was like, no, we’d rather work a little harder upfront. The consultant was huge to help us stay on pace and then cut us loose when we’re up and running and that’s what we ended up doing.
Cady: Yeah. If someone’s considering this option and thinking about doing it 100% by themselves or with an independent consultant like we did or going with one of those groups, I would say most simply put, the trade-off is a little more security and a little less administrative work and set up work upfront, going with one of these groups, and what you’re trading for that is autonomy and independence to make it exactly how you want it to be. And I’m sure different people would value those things differently.
Daniel: I’m still wondering how you got over that big hurdle. It’s like you had all the big things. You had a lot of student loans. The big organizations are like, nah, you’re too early in your career. You didn’t have the patient load. You are early into your career and you’re only two years in, at this point. You had mouths to feed. You had a house. And you didn’t have a big inheritance. You didn’t have a big influx of cash. What got you over that hump?
Ryan: Our second child was born right then! I think I had this real strong desire to continue to pursue that dream of having the career that I really wanted. Being the primary care doc that gets to practice and help people the way that I felt was best. And once we saw this model and could literally see it in action with one doc and then read more and more about it. A lot of the excitement came in and it was like, this is the last gasp here. This actually still is attainable. I don’t have to ride it off and like reinvent myself or whatever. And we’ve talked to other people around the country, other docs who were thinking about doing this and reached out and picked over brains or whatever. And I say it almost in gest, but then I’m at the end of the conversation with them and I’m like, no, no, no, I’m being serious. Cady and I both worked with individual therapists at that time. And I do think that really helped. I mean, we had each other to talk about it. We could see hope in the distance and a better way. And then the huge anxiety that came with having to feed the family and pay the bills and all that, I think working in therapy and getting that out made it to where it was surmountable. We kept going forward into what seemed like were essentially scary, fearful roadblocks or whatever.
Cady: Yeah. And I think it also helped us to recognize that bitterness, that resentment, that exhaustion, that terrible feeling you have when you’re working that hard every day and you can’t enjoy it. And you’re not happy with the quality of the work. The way that feels, it’s not worth paying your mortgage or the student loan. It’s not worth any amount of money. So really being focused on the fact that we’re really just trying to have our best life here. And that entails enjoying our work, creating a relationship with our patients, delivering high quality, primary care. If we can’t have those things, I don’t know. We’ll figure out what to do with the mortgage loan or the student loan. But it’s not worth living a life where those things are secure and accounted for without any question, yet you’re not content.
Ryan: And I think by being in therapy every week, you can’t hide from those emotions. And you can’t bury them. You can’t put them in the denial bucket. They just kept coming up over and over. So we had to address them essentially. And then we discovered a model that seemed like the antidote. So then it was literally just getting the gumption, you know. Like, okay, we’re going to get over this. And I’ll tell people this often. I think literally the most anxious day of my life was the day we went in to sign for the bank loans. On top of our individual student loans. And it was like, literally like putting all the eggs into one basket. And we’re going to sign for this bank loan and we don’t even have a space yet. And we’re going to make this thing happen from scratch. But you know, three years later, I’m thrilled that I walked into the bank that day. But I was very anxious. I’m not going to lie.
Daniel: Naturally! You can take two views of everything. You can say, everybody’s saying it’s never been done this way or young people don’t do it this way or you need to have an established patient or you need to closer to retirement or there’s no model for this. And that can be a reason not to do it. And that’s probably the natural gravitation. But you can also look at it like that’s an excellent reason to do it because that means there’s very little competition. We were working together then too and so from an outsider’s view, I was completely confident in you all. Either away, I was like, what’s the the hang up? Like, let’s do this! I have a lot of people where it’s not that way, where I’m not as confident. I was very confident in you guys mainly though, because you were following your passion. It was a values-based decision and I knew you would figure it out. I was completely confident and I thought it was a good opportunity. And I would rather go to a physician in that model and there’s just not any in our area, but that’s just kind of a different view. It seems like you all have gravitated towards that view and it’s worked out pretty well for you. Right?
Ryan: I think you’re right. Once I realized how much the concierge model made sense to the way the general primary was trending, I think part of the impetus and another thing that helped us get that gumption to move forward was that it seemed to make so much sense. What I didn’t want to see happen was discovering that, but then not pulling the trigger and then being late to the party when market would be saturated at some point, you know, it was good timing for us locally of, there was a few people doing this, there’s definitely demand, and I believe in this model. What I don’t want to do is wait eight or 10 years and then all of a sudden, not have the same demand that exists at the time. So you’re right. And I think, it seemed to just be lining up, even though at the onset it looked like kind of a crazy idea out of the gate. And I think having the consultant to help us, which we rolled that fee into the bank loans, that really helped us keep on pace. So we didn’t have a huge gap between when we finished that initial three-year contract and when we opened our office. One week. That was our goal. To be out of pocket for only one week because we really needed people to come with us. You do need some of those patients and there’s limitations about how you can reach out to them and that kind of thing. But now I can tell you that, the majority of our patients are not from our original office. We got probably just enough to kind of get the ball rolling. And,, we had some runway built in with a working line and all that stuff. But then once we were more established and we had a base of marketing we did and word of mouth referrals really started building. And now being essentially a full practice which is pretty amazing. We did not expect to be here at year three, but I think the demand is high for this. And, the word of mouth and new patients is ended up what sustained us, you know? So it made sense with the national groups that they didn’t want to do it early, because normally they don’t have to go out and recruit. They carve them out of the current panel. But with us, we really did have to build it, but there was just enough that kind kept us going. I still thank them to this day, the people who signed on out of the gate with us, because they gave us that space to grow.
Daniel: Yeah. So we talked about the stress that you guys had in the first job. And I know every job has stress. I’m curious how that has changed and what it’s been like, especially in the early days and the transition. I know we talked about the pressure in the prior job. As soon as you started the new business, did you release a lot of that? Or did it go to a different category or stress?
Cady: It was like a tradeoff, that’s not still there, but when we’re in this phase that we’re talking about where we have some patients, but not enough to pay the bills and the businesses is eating up the loan as we try to get more patients on board. During that period, it’s like, okay, the stress of seeing too many patients, not taking good care of them, having someone else tell you how to practice and what to do, that’s totally gone, but it got replaced with like all of our eggs are in this basket. Let’s not have the bottom fall out. So it’s definitely a different kind of stress. And also one that felt surmountable. We just have to get this practice to work and then this feeling will go away versus the stress and pressure at the old office, it wasn’t going to go away. That was just gonna stay there.
Daniel: And you can tweak it to make it better. You have control.
Ryan: Yeah, exactly. Being able to have your hands on the knobs and adjust how you want it to be done, that autonomy is huge and physicians just in general, I think are fairly autonomous personalities, you know. And then training even teaches you to do that more. So stand on your own feet, have the tough conversation, run the code, run the team, you know, make these really tough decisions for families. You don’t do that if you don’t believe in yourself and you are really encouraged to be an independent autonomous person. And then this idea that you go work for these places and they give you the space to doctor how you want and they take care of the printer paper and the insurance filing and paying the front office staff and you just go doctor, I think in theory makes sense. And for some docs, it really, really makes sense. And they do great in that. But for a lot, that autonomy they lost is too much because it doesn’t jive with the personality. But I think the new stress was essentially like, and I give Cady credit with this is, I mean, she basically got an MBA on the fly, you know, like becoming a small business owner. It was all these new stressors that we never dealt with or were never trained in.
Daniel: It’s like I got to set up payroll.
Cady: And all the types of insurance.
Ryan: Right. And then, ordering the couch for the reception room and the equipment with the stethoscopes and the otoscopes, and how do I hire people. So we worked with consultants, we worked with you, and different kind of entities to help us with whatever it was. And a lot of that actually is settled now. So we should do this again in three years and then, it’s really feeling good. Cause I do joke with people still, like at this point I think I still make a little bit less than what I made in the old office and work a little bit harder still, but it’s feels way, way better because I’m practicing the way I want, I am in control of my own destiny, and in three years from now, I don’t think that statement will be true anymore. It’s a journey and for us and our family, it’s made a lot of sense. But to say it’s easy or for everybody would not be true, but we’re glad we did it.
Cady: Yeah. Could never go back.
Daniel: That’s good. It’s fun to talk about it three years after too. If you’re talking to an earlier career physician or really anybody in general, that’s in that kind of high pressure environment and, is frozen. Maybe they’re frozen or maybe they’re just early on in that thought process. Any words of wisdom or specific suggestions you would throw out there to kind of help them get through that?
Ryan: I’ll give my 2 cents. I think I would say to two things, one, you could get some real practical advice and information by that one book that you read and Cady. It’s like the concierge startup Bible book. I can’t remember the title. But that gives you the nuts and bolts and a lot of practical type questions or whatever, and also find a physician who’s doing it locally that you can talk to. So that would be like the practical part of it. And then I think the flip would be honestly, finding a therapist, clergyman, a life coach, executive coach. Somebody to work through your frustrations about your current job with and help you focus in on your dreams for a future job. Because I think if you ignore that emotional mental health component of it, it’s easy to read the practical, but then just hit roadblocks of barriers of fear or concern or whatever. Cause you didn’t know what your goals are and what you don’t like about your current situation. And I think that’s really hard to figure out when it’s between your own years, And having a pro help you work through those clarifies it and then you can have the practical.
Daniel: I think if you’re a human, you should have a therapist. And especially if you’re going through a major emotional, transition because it’s be pretty stressful.
Cady: I was trying to find that book, but I would say it’s on this not so beautiful website. It’s www.conciergemedicinetoday.org and that is where I found the title to the book and found some lists of consultants and just my search for information about this style of practice. So that could be for someone who’s interested in just like starting to read and learn about it. That could be a good place to go. And yeah, I would say, I agree with what you two were just saying. I think the most important thing is really learning yourself and your priorities and then figuring out maybe you’re in a unique practice where you really can advocate for yourself and set some parameters, you have thoughtful administration and they have some flexibility and you say, these are my priorities and this is how I feel like they can be met. And maybe it’s that simple. I don’t think that’s the case most places, but there may be places where that’s true. And then, if that can’t be, if you find out where your true values and priorities are and your day-to-day life doesn’t line up with them, then it’s time to look for another option. And take the plunge.
Daniel: Don’t stay in something that’s painful like that where it’s against your overall goals and values. That’s just going to be bad for you.
Cady: Yeah, and as physicians, we know that better than anybody. We see in our patients all the time, how the stress of their day to day life implicates not only their emotional and psychological wellbeing, but legitimately their physical health. And then we also see in our line of work, that things happen that are out of our control with our bodies all the time. And it’s really not worth trudging along day to day in a life that doesn’t feel enjoyable. It’s not giving you meaningful relationships and value because you just, you don’t know what’s going to happen tomorrow. You only get one shot.
Daniel: Well, this has been fun. I’ve enjoyed talking through this and I appreciate you guys sitting down to chat through it with me.
Cady/Ryan: Yeah. Thanks. Yeah. Thanks for taking us back.
Daniel: Yeah. it was fun to see it from my perspective and I didn’t have to sign on the loans.
Cady: Goodness, but it’s worked out.