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“All too often, physicians and other health care providers have tried to do the right things for our patients to ultimately have had our hand slapped.
So pause for a second, get the questions answered, know what future implications are for today’s actions. Make the right choice for your patient, and for yourself, especially if it means amending your contract before you start something that may limit your talent/potential as a health care provider.
We are taught to feel powerless, which is why our burnout rate is so high. Words are disguised to mean another: patient volume/productivity disguised as patient access, EHR checkboxes that are clinically meaningless disguised as quality measures, your bedside manner, and ability to relate disguised as patient satisfaction surveys. And yet, as we see, despite being made to feel powerless, at the end of the day, we are the only ones with the ability to provide medical care when people need it. An anesthesia machine, scalpel, laboratory, and stethoscope are all useless without the person with it.
So get out there and wear your warrior uniform and help your patients! But don’t have it be a disguise for being made to wear shackles tomorrow.”
Vasanth Kainkaryam is an internal medicine-pediatrics physician.
He shares his story, explores his direct primary care decision, and discusses KevinMD article, “Advice to employed physicians plunging into telemedicine.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Vasanth Kainkaryam. He is an internal medicine-pediatrics physician. He practices in Connecticut, and he wrote the KevinMD article “Advice to employed physicians plunging into telemedicine.” Vasanth, welcome to the show.
Vasanth Kainkaryam: Thanks for having me.
Kevin Pho: So before we get into that, I was wondering if you could share your story and your journey to where you are today.
Vasanth Kainkaryam: Yeah, happy to. So my story goes back to high school, actually, where I entered a brand-new, health-focused high school, which hadn’t even been created yet. So it was sort of my first introduction to health care, thinking out of the box, experimenting with different things like integrative medicine courses and such. So it was always an interest.
And then I went to Cornell for undergrad, and my first year, I was actually diagnosed with cancer. So it was sort of an interesting time where, as a young patient, I got to see the turmoil of what happens in the family, how it affects yourself, your dreams. And I really got lucky because I got excellent care from the physicians around me. I remember that there are certain doctors that you just meet, and they just make you feel better, and I began to ask myself, “What is that magic that does it?” So not only do you have the science that’s fascinating, but then you’ve got this humanistic approach.
So after that, I decided to become a doctor. I went to Rochester for med school, which was really heavily focused on interpersonal relationships, and then I became a med-peds doc. So being someone who is boarded both as an internist and a pediatrician, after that, I did what I thought was what you normally do. You join a practice, a large system, and become an employed doc, because that seems to be what you do these days. And quickly, I got into a leadership role, working with people who are the thinkers of the system.
I got this really neat opportunity to work on building a direct primary care practice in Connecticut with a health care startup. To me, that was sort of my eye-opening experience, understanding what health care can be like if it’s not in the traditional setting, doing things like texting your patients, visiting them at home, all the things that are so simple and yet are so challenging, for some reason, to be done in the traditional health care world.
So as I sort of went on my journey, I became chief medical officer of a health system in Connecticut as well, focusing on the underserved population. And during my journey there, I actually became the guy talking to people about how many patients did you see, what was your volume, negotiating your contracts. And so I gained a very different perspective. But part of me kept looking in the mirror and saying, “You know what? How can I practice or recommend something that I’m struggling to believe in myself?”
So I left it. I decided to say, “You know what? If I can’t influence health care from the top down, I’m going to build it from the bottom up.” So I built my direct primary care practice last November. So right now, I’m a DPC doc, which is a model of care for primary care where you do not work with third-party payers, and it brings sort of that old-school medicine with modern technology.
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Kevin Pho: And how long have you been in direct primary care?
Vasanth Kainkaryam: I started in November in my own practice, but with the health care startup company, I was there for about two and a half years in a DPC model.
Kevin Pho: And how has the pandemic affected you and your practice?
Vasanth Kainkaryam: Yeah, you know, so if you think about it, direct primary care is fundamentally simple. It’s about the patient. It’s about what they need. So it’s very easy to pivot. So during the pandemic, where people are afraid to leave their houses, to be in situations where they might get exposed, it’s very easy. In a direct primary care practice, where it’s a month-to-month membership base that’s affordable, it’s very easy to say, “Hey, look, you know what? You don’t want to come in the office, totally cool. We’ll text, we’ll email, we’ll do video, without any additional cost to the patient.”
Kevin Pho: Fantastic. And I think, speaking of, we’re going to go to the article, “Advice to employed physicians plunging into telemedicine.” In a direct primary care practice, it seems like that virtual aspect of your practice comes naturally to you, but it didn’t come so naturally to a lot of us who were in traditional practices. So tell me about the story behind that article and some of the advice that you would share with those physicians who were plunged into telemedicine.
Vasanth Kainkaryam: Yeah, you know, as I saw more and more folks get into telemedicine, it just occurred to me that, you know what, there are so many people, even from my own experience, who sign contracts and, when they want to leave their job or they want to do something else, actually don’t know what they’ve signed. And it’s fascinating, because some people use lawyers to interpret, and some people don’t.
So as I saw more and more people getting into telemedicine, and we’re talking about how doctors and nurses are our heroes, I didn’t want people to be blinded by trying to do the right thing. Don’t end up putting yourself in a box where you limit your own options. So it stemmed from understanding how contracts are written, how many of them are written in favor of the employer, and how many physicians in particular don’t really know what they’re signing, or they don’t know how to keep their options open.
And so many folks who signed agreements, telemedicine may not have been a part of what they do when they signed it, and restrictive covenants are very different state to state. So I didn’t want people to put themselves in a situation where, all of a sudden, when telemedicine is going to be a big part of our future, you’ve limited what you could do.
Kevin Pho: So what’s your number one tip for these physicians who are using more and more telemedicine?
Vasanth Kainkaryam: Yeah, I think you’ve got to go back to what you have committed to with your organization. If they’re asking you to do something that’s beyond what you had committed to, go back to that language, and make sure that what you’re about to embark on is not something that, should you want to do it independently, you won’t be able to. And I think, to be honest, for some of that, you might need to end up consulting with a lawyer to truly understand how that language is written and whether you end up getting restricted.
Kevin Pho: We’re now talking in the third week of June, and we are months into the pandemic. Is there something that you know now that you wish you knew back before the pandemic started?
Vasanth Kainkaryam: Not necessarily. I think, in many ways, the reason I chose DPC is because of the flexibility. And I think if there’s something that surprised me, it’s actually a little bit more disappointment, in that so many people have been working hard to innovate in health care and to try to do the right things for the patients, and yet it took over 100,000 people to die in our country for us to do anything about it. There’s so much initiative, but there always seems to be red tape and bureaucracy. But all of a sudden, now that so many people have died, it’s OK to do it. It doesn’t make sense to me.
So for me, what I want people to think about is to reflect on what’s driving our policies and regulations, and if you don’t agree with it, speak up. Because clearly it’s OK during a pandemic. Why is it not OK on a normal, day-to-day basis, when you just try to do the right thing for a patient?
Kevin Pho: So states are starting to open up. How do you see the next few months playing out, and specifically, how do you see it affecting your direct primary care practice?
Vasanth Kainkaryam: You know, my direct primary care practice has actually continued to grow. And if you look at direct primary care practices across the country, they continue to grow, which is very interesting, because some of the private practices have actually really struggled because of the inability, sometimes, to pivot. And so I expect continued growth in the DPC market, because we can do simple things. We can do home visits. We can do virtual visits. We can say, “Hey, you know what? Let me give you your shot in our parking lot.” Things that would be unthinkable in traditional health care are possible in DPC. So I expect that to continue over the next few years, and I actually expect more and more people to look toward models like DPC.
Even take telehealth, for example. Right now, it’s being reimbursed by many payers, and a lot of payers are reimbursing it at the same rates as in-person visits. Once patients begin to realize that those potentially could be applied toward deductibles, they’re going to start asking questions: “Well, is my in-person visit going to cost me the same as a phone call with a doctor?” And there are going to be questions as to how we’re paying for this. DPC solves all of that, because all you do is you pay your membership fee, and you don’t have to worry about anything else.
So I think there are going to be more and more options. People are going to want to know what choices they have, and those who have insurance are going to begin to see the effect of this high-cost year in their premiums next year and are going to start asking, “Well, how can I save money and still get good care?”
Kevin Pho: So I have a lot of primary care clinicians who listen to this podcast, and they may be listening to you and think, “You know, direct primary care sounds pretty good.” What are some resources they can read to maybe think about that transition?
Vasanth Kainkaryam: Yeah, so there’s a large alliance. The Direct Primary Care Alliance is a fantastic organization filled with DPC docs who help support each other. There are excellent books written by DPC doctors on how to start a direct primary care practice. There’s a lot of free information available, and there’s actually a very large Facebook group of over 1,000 direct primary care doctors across the country who really help support each other and troubleshoot some of these uncertainties.
That being said, DPC is a risk. And so if a doctor is thinking about doing direct primary care, you’ve got to be comfortable with the fact that you might be taking a three-figure pay cut, and you might not make any money for a year, a year and a half. So there’s a degree of risk tolerance that you need to have if you’re thinking about breaking from the traditional world, and how that financially will work for you.
Kevin Pho: Well, thank you so much for sharing your story and your insight. My final question: What’s your take-home message for the KevinMD audience?
Vasanth Kainkaryam: Yeah, my take-home message is: Don’t forget you have a choice. I think many of us in health care, and patients in general, are trained to think we don’t have choices, that this is the way health care is, and whether we agree with it or not, we go with it. And that’s why you have a 40 percent burnout rate for physicians, and that’s why patients are frustrated. A lot of us don’t know we have options. We have options in how we get care, we have options in how we deliver care, and we have options in how we pay for care. It doesn’t always have to be insurance. There are other models out there.
So my biggest takeaway for everyone, to me, you know, I tell my patients, “It doesn’t matter whether you join my practice or not. For me, I’m not looking to sell this to you. I want you to make the right choice for yourself.” And if what you walk away with is knowing you have a choice, to me, that’s a success.
Kevin Pho: Well, thank you so much for sharing your insight. A lot of us are plunging into this virtual world, and it’s great that you gave us some wonderful advice. On the show, we have Vasanth Kainkaryam. He is an internal medicine-pediatrics direct primary care physician. He wrote the KevinMD article “Advice to employed physicians plunging into telemedicine.” Thank you so much for joining me on the show.
Vasanth Kainkaryam: Thanks, Kevin.
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