Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

Join Maryal Concepcion, a family physician, as she shares her inspiring story of transitioning from a traditional health care role to direct primary care (DPC). Discover how the values of social harmony and interconnectedness from her collectivist upbringing influenced her approach to patient care, and learn about the transformative power of the DPC model. We’ll delve into the challenges she faced, the importance of cultural heritage in health care, and her message of hope for a more inclusive and equitable future.

Maryal Concepcion is a family physician.

She discusses the KevinMD article, “Bridging care and culture: a Filipino doctor’s journey in direct primary care.”

Our presenting sponsor is Nuance, a Microsoft company.

Together, Microsoft and Nuance are leveraging their rich digital technology and advanced AI capabilities to tackle some of health care’s biggest challenges. AI-driven technology promises to revolutionize patient and provider experiences with clinical documentation that writes itself.

The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled solution that automatically captures patient encounters securely and accurately at the point of care. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows.

Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 85 percent of patients say their physician is more personable and conversational.

Discover AI-powered clinical documentation that writes itself. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://kevinmd.com/cme

I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://kevinmd.com/learnerplus

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Maryal Concepcion. She’s a family physician. Today’s KevinMD article is “Bridging care and culture: a Filipino doctor’s journey in direct primary care.” Maryal, welcome to the show.

Maryal Concepcion: Thank you so much, happy to be here.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Maryal Concepcion: Yeah, well again, I’m so happy to be here, it’s an honor. There have been over five articles just on direct primary care on your platform over the past year I believe, and so it’s wonderful to join even a fellow Filipino doctor, Dr. Grace Tus Hodes, who was previously on your show.

I am a person, like I put forth in my article, who grew up in a society filled with all of my Filipino cousins and aunts and uncles, and everybody is related by blood at some point. And what I really loved, that I didn’t recognize until I was away from Sacramento, was that everybody was there to help each other succeed in whatever you were doing. Whether you were a teacher, whether you were a lawyer, whether you worked for the state, everybody contributed to a place where you could express your wins, your struggles, and we would work things out together to help everybody succeed. So that’s what was represented when I used the word collectivist in my article during Asian-American Heritage Month.

Kevin Pho: Excellent. Well, tell me about your practice. What’s that like?

Maryal Concepcion: Yeah, so I practice in rural Northern California. I have a micropractice, meaning it’s myself, my husband who’s also a family physician, joined in September of last year, and we have a virtual assistant. And it’s just the three of us running our entire clinic. Our clinic is a direct primary care practice, thus my mentioning the DPC model on your platform earlier.

And this is a model that both my husband and I went to after being employed by a corporation for almost six years in my case and a little over eight years in my husband’s case.

Something that I did not really get into in the article was that my journey into direct primary care was somewhat of a ripped Band-Aid feeling journey. My employer at the time was saying that I needed to sign a contract, which I did put the details on in the article, where there was a very big lack of transparency as to reimbursement rates, where if I worked for another company they would own my money, all of these issues. And the proposition was, you either sign our contract or be fired.

And so I was completely dumbfounded. I had not been prepared in residency nor in medical school or any part of my training to think that a physician would not be valued by their employer. And I also only knew about being an employee at the time. And so branching off into my own clinic, my husband joined after it opened, was definitely again that Band-Aid being ripped off feeling.

But we are successful, and because this model proves over and over again that no matter where you are in the country, this model is a successful way for patients and doctors to develop a relationship and save money and get better care all around.

Kevin Pho: All right. So you talk more about that journey in your KevinMD article. For those who didn’t get a chance to read it, tell us more what it’s about.

Maryal Concepcion: Yeah, so what I’m highlighting, especially because of being a Filipino doctor growing up in that collectivist society like I shared, DPC really embodies the things that I loved about my family and growing up in Sacramento, as I did in the medical field.

So when I say that, what I mean is that direct primary care not only allows me to be there for my fellow physicians who have chosen or who are thinking about DPC, but it also allows me to build that relationship with my patients.

You know, I had a 16-year-old in my clinic in residency, and it was so sad, she passed away from a very rare gastric cancer. But the entire time that I was taking care of her as a resident doctor, the mom was so suspicious that I was giving her suboptimal care because she had Medi-Cal.

And now I’m able to say, I don’t care what insurance you do or do not have. I encourage someone to have insurance for issues that are requiring insurance, hospitalization, surgeries, emergencies. But for me to be able to have the time I need with each patient, and that’s individualized by their needs at the time, it’s amazing.

And so DPC to me is that collectivist way of practicing medicine, and I am so glad that I know about it now. Clearly I talk about it every week on my podcast. But I wish that this was something that somebody had told me earlier. I just went into family medicine assuming that people would be like the attendings that I saw in training, you know, very supportive, very passionate about full scope care. But that’s not what I saw when I went into employed medicine post residency.

Kevin Pho: How did you find out about DPC?

Maryal Concepcion: Yeah, so it’s so crazy and sort of sad that I learned about direct primary care from an orthopedic surgeon. This orthopedic surgeon was so burned out and tired of the policies, like, that’s nice, it doesn’t matter what kind of material you want to use for your hip replacements, we’re going to get these in bulk and this is what you have to use. And this orthopod left the system, branched out from the corporation that we were both working for, opened his own clinic, still thriving to this day. But that’s how we learned about direct primary care.

And this is why I love to point out that direct primary care, that collectivist feeling, not only is pertinent to primary care, even though that’s the legal term that is in the ACA and protected in many states, but it is a business model. So we see specialists all over the place, cardiology, rheumatology, dermatology, GI, surgical specialties, who are choosing to do a direct model, even if it’s not their full way of delivering care. They’re still able to bring an option to their patients and cut down costs and increase accessibility.

Kevin Pho: Now we talk about direct primary care several times, like you said, on the show and on my blog. For those who aren’t familiar with it, give us a 30-second description of what exactly direct primary care is.

Maryal Concepcion: So I have a little cheat sheet, because this is the opening to my podcast. But direct primary care is an innovative alternative path to insurance driven health care.

And so what that means is the patients are investing in their doctor directly. And so the doctor is enabled to then feel, one, valued, which is something that a lot of physicians do not feel these days. And then secondly, they’re able to look at their clinic and make sure that they’re doing the best type of medicine, giving the best accessibility possible for what works for their life. Like if they have little kids like myself, that means I don’t work eight to five, five days a week. But you get to craft your own way of delivering care, because at the end of the day your patients are buying into what you’re bringing to the table.

And for me that is just so rewarding, compared to the system that I left, where the random admin who’s not even in clinical medicine whatsoever, nor clinically trained, nor with any degree in clinical medicine, is saying everyone must have an A1C of 7.1. Now I work for my patients, my patients invest in me and I take care of them, because that’s the value proposition that I’m bringing to the table.

Kevin Pho: Now you were at a traditional employed model like a lot of primary care physicians were, and you were up against a lot of the obstacles that they have to deal with, whether it’s metrics and EMR and administration. So you heard about this direct primary care model, it did appeal to you and your values. Tell us about that transition itself. How difficult was it for you, and tell us about the challenges that you faced transitioning from that employed model into something that is relatively new and innovative.

Maryal Concepcion: So this is a great question, and something that I get a lot, especially from residents and medical students who are considering doing DPC in the future.

What I will say is that the number one challenge is just healing from being an employed physician. I think that you go into thinking that I am valued, and then you get beaten down. That was definitely the case that I experienced, and many of my colleagues who do DPC have experienced, where you really lose your sense of value.

And then we very often forget, when we’re going into the entrepreneurial space, we went to doctor’s school, that means we have a lot of smarts under our belt, and that means we can be entrepreneurs. And so that was I think the biggest thing, that some people say mindset change. For me it was just recognizing that I could do this, and that doing things that are hard is definitely possible. We all went to medical school. Opening a business, there’s steps, it’s very much more formulaic versus all of the things that we went through in medical school.

And so the transition, I definitely would say, was a little bit different for me, because I knew that I was going to do DPC before I left. And so my runway in terms of financially preparing, in terms of doing my research, was definitely longer than some people’s. Some people have six days to transition, some people have years.

And so for me, knowing that I had spoken with many direct primary care doctors from all over, people who had just opened, people who are preparing, people who have been in practice for five, 10 years, that allowed me sort of a crib sheet to open my DPC. So I started with very, very low overhead. I had a home visit and telemedicine model only, and so that allowed me to not have to pay rent upfront, and within five patients joining my practice I was in the black.

And so I say that just to point out that direct primary care really is, you need to show up as a doctor, and however that manifests in terms of space, in terms of access, that’s up to you and what your patients value. But you do not have to invest a ton of money and resources into opening a direct primary care, especially nowadays when there’s so many people who have done it in every single state in this nation, that there are resources a lot more plentiful now than there were prior.

Kevin Pho: Now you mentioned that you had a lot of mentors and you talked to a lot of other DPC doctors. How did you find them? Was there a website, were there resources, did you listen to podcasts? How did you find these mentors before you actually transitioned yourself?

Maryal Concepcion: Yeah, so I was a person who, once I found out about direct primary care, I like to say that it’s like Neo taking the red pill. I went to every single conference that I could, because I met people in person, and from there I was able to hear stories.

What I realized though at the time was, yes there were books, and yes there was a podcast at the time that’s no longer in production, but I was left with, I want to know more, I cannot get enough of this. And so that’s where I created my own podcast, where I am active on the direct primary care Facebook groups for physicians. I try to be as present as I can at every single conference that is direct primary care focused or related, so that I can continue meeting people.

Because it’s through networking with others that I highlight on my podcast the different ways that people are delivering care. And by doing that, by talking with people, not only does it make me think about DPC differently, but when I hear a person asking me questions, I’m able to direct them to these different models of how people are delivering direct primary care.

And that’s to me, you know, my podcast is called My DPC Story for a reason. It’s the stories that I really clung on to when I went to conferences, and this is what I’d like to highlight, the stories of DPC doctors all over the country.

Kevin Pho: So I believe that you practice in a relatively rural setting, is that correct?

Maryal Concepcion: Yes, it is.

Kevin Pho: So talk about that intersection between direct primary care, that model, and how it fits rural health care.

Maryal Concepcion: Yeah, so the rural setting in particular is so in need of quality health care. Unfortunately in our area the nearest emergency room is 45 minutes one direction or 45 minutes the other. If you are pregnant, your options for seeing an OB are very limited. Since 2015 my husband and I have been the only physicians in the entire county to offer obstetric care. That is so sad. We’re in California, people don’t assume that there’s places this rural.

We don’t do deliveries any longer, but we do provide obstetric care. We provide care to the entire span of a person’s life, from prenatal care, newborn, all the way to in-home hospice.

And so in rural America, one, our patients, no matter how old they are, our average age is around 46, that’s what I found yesterday. But my patient panel in particular compared to my husband’s definitely swings older. And all of our patients minus a few have insurance. Most of the time they have double insurance, Medicare plus some supplement.

But what they find is that, one, they want a physician. That absolutely matters, because especially our older patients, they recognize the training difference of a physician compared to a non-physician provider. The second thing is that in terms of accessibility, when your nearest urgent care is 30 minutes away and it’s only open, I think it’s like eight to four, four days a week, that really limits your options into how to get care.

And so as we’ve seen with multiple DPCs all over this nation, when you not only have access and your doctor knows you, that’s what our patients tell their neighbors and their friends, and that’s how we’ve seen this crazy uptick in direct primary care and in patients joining onto our practice. Because they’re like, wait, that’s unheard of, I want that.

And you know, there’s even data out there to show that, I know you asked about rural, but just to put a point here, that if you are a company who has employees even in a rural setting, you can offer these services to your employees. We’ve seen an uptick, there’s one set of data that shows between 2018 and 2022 an over 800 percent adoption of direct primary care centered plans in this country.

Kevin Pho: So have you noticed any headwinds from local hospitals or traditional physicians who push back against your model? Any opposition to what you’re doing in direct primary care?

Maryal Concepcion: Yes. And when you say that, it’s like I immediately envision Star Wars, it’s like there’s always going to be good versus evil.

But to me, what I focus on is that DPC is growing like wildfire. There are DPCs opening left and right in all different states, and that is because physicians cannot stand when they’re being devalued. And physicians are clamoring for a way to not only take care of their patients in a better way with more time and more access, but also to have a model that allows them to do whatever they want. If they want to do musical theater, great. If you want to have a bookkeeping business on the side, amen. But we could not do that as a group in the employed model.

And so yes, there are people, like in California the data from the California Academy of Family Physicians shows 86 to 90 percent of residents go into employed medicine. But magically this year, I’m going to be doing a talk at the state medical student resident conference about direct primary care, because the ask is out there. The, I need to know what my options are, is being demanded.

So no matter what system exists today, for me I focus on, what’s the system that is better for all of us, physicians, non-physician providers, and patients? What can we do to optimize what we’re doing going into the future?

And we see that just right now there’s more bills about direct primary care that are live on Capitol Hill than any other primary care model. We also see that this is a time where we’ve had calls into the investigation into private equity from the Federal Trade Commission, Department of Justice, Health and Human Services, and then with the Department of Homeland Security jumping on the boat because private equity is affecting emergency rooms.

I mean, we are at such an amazing time in health care, and this is where I encourage people to know what are the options out there. And it’s so much easier again, because there’s so many of us doing direct primary care as a primary care or business model, that it’s easy to find a mentor.

Kevin Pho: Now, are there any types of physicians who may not be a good fit for direct primary care, or that you would advise against going forward to direct primary care?

Maryal Concepcion: So maybe three or four years ago I would have said it would have been harder for people to go into DPC if they weren’t entrepreneurial, in terms of they wanted to open up their own business. Now I’m so excited to say that that’s not an issue. There’s so many DPCs that if you don’t want to start the business, if you don’t find that exciting, that’s OK, you don’t have to start a business anymore. You literally can pair with another direct primary care doctor, and that doesn’t even have to be in the same building. You can pair with another DPC doctor in the same state if you’re licensed in their state, and offer just a telemedicine branch of their DPC.

When it comes to the physicians who this is not for, because it’s such a global question and it’s a fair question, there are more hesitancies when it comes to surgical specialties. But again, there are surgical centers that are only cash pay in this country and they’re growing. There’s a small number, but they are growing. I went to a locums conference in Las Vegas earlier this year, and nobody in the room was a primary care doctor except for myself and another pediatrician, and everyone was like, wait, I could do a DPC branch of my surgical specialty, or fill in the blank specialty.

And so when I think about the physicians who it’s not for, if a physician can look at their job and they can say, yeah, I’m totally fine not rocking the boat, staying status quo, getting my 401(k), my salary, whatnot, that’s great. But I do say also that those people, I do recommend taking a look and making sure that medicine is still allowing you to be you. If it is not allowing you to be you, and again, you can be a very vague thing, because everybody has different interests and hobbies and everyone’s at a different stage in life, but if your career is not allowing you to be you, then I would encourage people to look into direct primary care.

Kevin Pho: What do you say to those residents who have hundreds of thousands of dollars of student loans, and they may be tempted by the allure of a guaranteed salary and an employed model? What do you say to them if you’re trying to introduce direct primary care to them versus a traditional practice?

Maryal Concepcion: So what I say is that, and you’ll hear this in direct primary care, that those are the golden handcuffs. I was just watching yesterday a person who makes chocolate structures, and he was spray painting the chocolate with gold spray paint. And to me that’s exactly what these things are.

When you get a seven-year mortgage paid, that’s amazing. But at the same time, if you’re expected to see 40 people in a day, and you don’t have time for you, you are not showing up as the best person you can at home for your family. It’s the pros and cons, and you have to balance those.

What I will say though for residents and medical students, especially because of where we are in the DPC movement, is that once you are recognized as a board certified physician, you can start your DPC. So there are multiple people on my podcast who have opened while in residency. And I even have a series of interviews where four different people, family medicine, pediatrics, and internal medicine examples, have shared their story while preparing, right after residency, year one, year two, year three anniversary, and this year will be their year four anniversary.

So to those people I say, DPC is definitely a way to earn a living, to earn a decent wage, so that you’re not having to think about money. There are different ways to do it. And I think that medical students and residents have a much bigger advantage compared to somebody like myself in my 40s, because they have the ability to learn and explore DPC earlier on. So creating that financial plan is definitely something that is doable, whether you take side gigs, whether you take side gigs in DPC or an urgent care, whatever it is, or just look at how you are investing your money differently. When you have more years under your belt, you have a greater runway to prepare.

Kevin Pho: We’re talking to Maryal Concepcion. She’s a family physician. Today’s KevinMD article is “Bridging care and culture: a Filipino doctor’s journey in direct primary care.” Maryal, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Maryal Concepcion: So to the audience, what I would say is that I have truly flourished in direct primary care, not only as a doctor but as a person. There are ways to do DPC in a nonprofit model, in a for-profit model, in a big group, in a micropractice with no staff. The options are limitless.

And so if what I’m speaking to, and the other doctors who have been on KevinMD, whether in the blog or on the podcast, have shared theirs, learn about direct primary care. There are so many options on Facebook, there are conferences. I definitely would say go to mydpcstory.com, on our resources page you’ll find all the DPC focused conferences, and plan your year around them.

But learn, and know that you are valued as a physician, and this is a model of care where no matter where you are, you can create a collectivist society around you, because that’s how patients and doctors end up being in DPC, supporting one another, so that this model can flourish.

Kevin Pho: Maryal, thank you so much for sharing your story, perspective, and insight, and thanks again for coming on the show.

Maryal Concepcion: Thank you so much for having me.