Private Practice Pathways: What Options Are Out There?

Jennifer Spector, DPM: Welcome back to podiatry today. Podcasts where we bring you the latest and foot and ankle medicine and surgery from leaders in the field. In this episode we are honored to have two fantastic docs with us to talk about their experiences in private practice. Earlier this year Podiatry today published a roundtable discussion about multiple types of practice settings from DPMs across the country. We are thrilled to have these two particular DPMs with us, to share their thoughts as they each have unique takes on a private practice structure. I'll have them introduce themselves shortly. But first welcome and thank you so much for being with us today.

Tea Nguyen, DPM: I'm Dr. Tea Nguyen, and I own a direct care for nitro practice in Santa Cruz, California. I specialize in minimally invasive surgery. I perform these in the office to help people walk faster with minimal downtime and to help heal ulcers without leg amputation.

Alissa Kuizinas, DPM: Hi! Um, my name is Alissa Kuizinas. I am a podiatrist practicing outside of Boston, and I have a combination style practice where I do part virtual and part in person. My specialty is really musculoskeletal disorders, sports medicine, and really holistic health.

Jennifer Spector, DPM: So each of you really do have unique takes on private practice. Dr. Kuizinas, How did you come to practice in this particular type of environment?

Alissa Kuizinas, DPM: Yeah. So my practice kind of evolved as my ideas around how I wanted to treat patients evolved. I started out in a very traditional private practice, setting, and after a while I started to realize that I wasn't crazy about the way that I was practicing. I felt really rushed. I felt like I was never really addressing the root cause of anybody's problem. So, I sort of took a time-out from that kind of structure, and I decided to really relearn how to treat problems by dealing with the underlying issues. And so, in order to really do this, I realized that I had to kind of kick the old model aside, and I started just seeing patients virtually where I could give them as much time as they needed. Usually I would have hour-long patient visits and I could really do a lot of education, and things like that, and that eventually sort of bloomed into more of a combination type practice where I eventually took that and turned that into what I could do in person in the clinic as well.

Jennifer Spector: Dr. Nguyen, how about you? What was your experience that led you to your particular style of practice?

Tea Nguyen, DPM: I opened my private practice in 2018, essentially because I was unemployable. There was nowhere to work, and I had left a previous practice, but it wasn't really a good fit for me. It was also the year that I had my daughter, Violet, and so I was dealing with being a new mom, and I was like, why not just throw in private practice on top of that? Because, you know, we're all crazy, aren't we, let's see how this manifests. So, I open the practice with the insurance-based model, because that's what everybody else is doing. And so I just kind of followed along the current. And then about a year into my practice, I was still knee deep into my debt to pay my overhead to pay for my staff, and then I got these three individually stamped envelope by the insurance company for my reimbursement for the services that I rendered, all of them which were less than ten cents, and I was really annoyed. I was fed up. I thought, how can I possibly sustain my practice as a solo podiatrist in this small community of low-income people with checks coming in this way. It just feltnreally wrong for the for the type of work that I was providing, and what I was getting reimbursed at, and so I decided to shift my practice into direct care, which is a hassle for your way to practice medicine without relying on insurance reimbursement, but rather the patient pays me directly, and they can have all the time in the world to get their problem resolved in one visit. So I did the shift in two thousand and twenty. At the beginning of the pandemic I started learning more about minimally invasive surgery, performing this in the office rather than having to go to the hospital or surgery center. I can certainly still do that. I maintain my credentials to do that, but I pushed all of my elective surgeries in House, because ultimately these only require local anesthesia, and I was already performing these procedures in the room care center. So I said, why not expand my reach and make medical care much more accessible? So now i'm currently a hundred percent cash surgical practice.

Jennifer Spector, DPM: So what drew each of you to private practice, independent of the type that you actually have right now versus an employed practice. I know both of you have sort of mentioned, possibly past experiences not being a great fit. What made you think that private practice was the way to go for you?

Tea Nguyen, DPM: Oh, yeah, my tagline is I'm unemployable there. I live in Santa Cruz County. So you're either working in the system or you're in private practice, and working in the system just didn't apply to me. They required a lot of call, they required certain types of academic background which I didn't have, and so I kind of took that as a blessing that you know, maybe I didn't want a life where I was on call all the time. I wanted to stay where I lived, and the only option at the time was to open my own practice, to have that flexibility in my schedule, and to live where I work so that I really didn't have a choice. To be honest is what it came down to.

Jennifer Spector: Well, it seems like it worked out in your favor most definitely. What about you? Dr. Kuizinas, what led you to private practice specifically versus being employed?

Alissa Kuizinas, DPM: Mostly two things for me. The first thing was that I really wanted to be able to practice the way that I wanted to, in terms of how how I saw patients, how long I could see them for and what treatments that I would do, and I didn't want that to be dictated by having somebody else dictate them for me that I was working for, or having to deal with the system that required certain outputs. I just knew I didn't feel comfortable practicing that way anymore, and it just didn't feel like a fulfilling career for me long-term. So that was pretty much the first thing that kind of pushed me into going out on my own. And then the other thing, which is really big, is just being able to have, the flexibility and to be able to make my own schedule. Um, and to know that you know I could kind of evolve my practice with myself as I go along. So those two things were super important for me.

Jennifer Spector: Well, now that both of you have have been in this type of practice, what do you feel is the best part of that practice setting and that practice structure. 

Alissa Kuizinas, DPM: For me the best part is being able to kind of define who my kind of ideal patient is, and this is something that I never even considered before. But I sort of realized that,  there are certain things that I really enjoy doing, and then I feel like I'm really good at versus other things. It's really cool when you build your own practice, and you can kind of figure out what you love to do, and then the things that you don't love to do. You know you can rely on your colleagues for, and you can refer out, but sort of having more of a vision of what types of patients you want to be treating, what kinds of pathologies you want to be treating. This really helps you to  build the life that you want to live versus one that you feel kind of stuck inside. So that for me has been really awesome about private practice and being on my own, which I always struggled with before, when I was working for somebody else.

Jennifer Spector, DPM: Dr. Nguyen, what's the best part been for you for this practice type that you've created?

Tea Nguyen, DPM: I could bring my daughter into work, when I built up my practice. It was from the ground-up; I had to undo the floor, the paints, the doorknobs, the door, and so I had this period of time where it was just me and my daughter in the office and in the back office. I would have her crib with me, and so I would have my staff look over her as I was in between patients, and I think, just realizing that there is no other employment situation that could give me that type of freedom that I wanted to have to be with my daughter, to fulfill my obligations as a mom that I wanted to, and but also to be an excellent surgeon. So I wanted to be able to control my schedule, and nobody would ever give that to me I would have to create that for myself. So at this point I don't know if I can ever go back to an employed situation. I'm not saying the door is completely closed, but it's quite lovely on this side.

Jennifer Spector, DPM: No, absolutely. And even though it's lovely on this side, I'm sure there's always some roadblocks that we all encounter. Have you run into any challenges? And if so, how have you addressed those?

Tea Nguyen, DPM: I think, is essentially the same for everybody. We have to deal with hiring and firing staff and training them. We have to learn how to speak like a marketer, and tell people what we do in the way that we'll make them listen and to come to us to solve their problem. So these are business skills that a lot of us are intimidated by mostly because we don't have that experience. When we're employed, someone else is doing the work for us. But when you build your own practice, you actually have the freedom to build it exactly how you want, and, like Dr. Kuizinas says, you can tailor your marketing message, so that you see exactly what you want all the time doing only the things that you want to do, and I think the trade off is, you have to put in a little bit of a little grease to get that going for you versus when you're employed that all the work is done for you. So you don't really get to build up that skill until you have to. So the challenge is the same. It's just business building and learning how to speak a different language when all we really know is medical jargon.

Jennifer Spector, DPM: Dr. Kuizinas, what type of challenges have you encountered?

Alissa Kuizinas, DPM: I agree with exactly what you said. It is a really different kind of mindset, and and you're looking at it from the business side of things so you know, especially in the beginning. It can be um little bit more difficult to find patients. You have to have trust that the patients that you know need you are going to come to you and find you. But I think there is really,  a good side with that. You're building. You know exactly what you want to build. And as you go on you become a lot more comfortable with those decisions, and really doing all that kind of stuff, doing the marketing, and attracting um patients to you. But it's a little bit intimidating in the beginning, because we're really not trained for that. I think throughout school and residency. we don't get any of that business training, and we don't even really think of what we do as a business. We think of it as just a service, and you know, when you work for somebody else you kind of just kind of fall into that.  No matter where you work, it is, still it is still a business. And so, just to kind of learn those aspects of it, I think, is actually really helpful. It's a big shift, but once you get there I think it's super worthwhile.

Jennifer Spector, DPM: What resources did you use that were really helpful for you when navigating all of those points of private practice, like Dr. Kuizinas said, "we don't learn this in school." So what resources did you use to help you get the knowledge you needed to succeed?

Alissa Kuizinas, DPM: I used a lot of different resources. Everything that I started with was very virtual. I took different courses online not all necessarily one hundred percent related to health care, but certainly some just business oriented courses, marketing courses just things like that. I have a very wide collection of resources that I use, and the practice model that I have is pretty unique. So there's not really a lot of people that are doing something very similar. So I kind of piece things together on my own, which is a little bit trickier. If there had been some one out there that, you know, had done this before, it would be a lot easier. But yeah, I really kind of reached from different categories of online business. And you know, health care business and things like that., speaking with other health care practitioners who've done similar type of things with their practices. But, a lot of it is just kind of figured figuring things out of my own. For sure.

Jennifer Spector, DPM: You are blazing your own path, and that's a good thing. Dr. Nguyen, What kind of resources were helpful to you in your journey?

Tea Nguyen, DPM: I think I underappreciated human capital, other humans who have done what we want to do. But perhaps we don't see, you know, how to put piece it all together. So for the same reason as Dr. Kuizinas, that for me I had no model to follow, because I wanted to do a very specific thing in my practice. They had existed in different forms in different podiatrists in different specialties, and I found that just talking to people getting really curious as to how they got to where they are getting into their brain, reading what they're reading. Listen to what they're listening to. I think that's kind of the best way to learn. You read something, and then you put it into practice. You don't just read until the end of time, and then, you know life is going to give you those lessons, and so i'm an action taker. So if somebody tells me this is what they did, i'm going to find a way to apply it to my own scenario. I'm going to learn from the mistakes that I created on my own, and then i'm gonna move on from that. And so I think that is just kind of the mentality you have to go into when you run your own business. Is that there really isn't a blueprint. There is no book that says, Do these things, and don't make these mistakes when in reality you have to make mistakes to make it work for you, and then you learn from them. So it's just the human capital for me. It's just talking to as many people as they possibly could, and trying to weave them together to make it my own thing.

Jennifer Spector, DPM : being that both of you are are creating that blueprint of sorts for the future generations of practitioners, what do you think that these newer individuals in the field, especially students and residents, should know about private practice of any kind?

Tea Nguyen, DPM: Private practice is building up the first couple of years. You're going to work really hard to figure out what you want to do, because you may not know what you want to do until you do the work, and then you start processing things out, like maybe I didn't want to do that, after all. So I think the most important lesson that I learned in my journey is that you will make mistakes. You can't always prevent them, and most of them are necessary to give you that business acumen that you didn't have before. And so those mistakes or failures are really lessons, and so embrace them. Learn from them, and just expect more will come the bigger your practice grows.

Jennifer Spector, DPM: Dr. Kuizinas, What do you think students and residents should be learning about these opportunities.

Alissa Kuizinas, DPM: Yeah. Well, first of all, I think they should, you know, really be aware that private practice is not over or ending, which is something that I was told over and over again when I was in school and residency. The conversation then was that nobody is going to be in private practice anymore, and everybody is just going to end it, being kind of bought out and working for big companies. And I think that literally couldn't be further from the truth. I think now there's so many more opportunities to kind of create what you want, and to go out on our own, whether that's fully in a private practice, or whether that's in sort of a combination type, practice. So just being aware that you really don't have to follow any kind of prescribed path. Whether you've seen somebody do something or not, it's possible to do it. You can always change your mind. It's okay to just get a job first, and figure out what things look like, but you can always go to the next step, and you can always kind of figure out something new, and I think there's just more more opportunities to do that as time goes on, which is really cool.

Jennifer Spector, DPM: Speaking of more and more opportunities for people who are already in practice. What do you think that DPMs in more mature stages of practice could learn from your experience? Do you feel that these opportunities still exist for somebody that's been practicing for five, ten, fifteen years, or more?

Tea Nguyen, DPM: Definitely, i'm in the fourth year of my practice, and i'm a hundred percent cash, and there are people in their private practice choosing to go into a direct care practice after fifteen or twenty years of their insurance based model. So there's always something new to learn,
and there's a community that's growing. And so, whatever phase you are in your private practice, there's always something new to learn.

Alissa Kuizinas, DPM:  I agree. I think there's always an opportunity to change or to pursue a new style of practice, whether you already have a private practice or or not. I think there's opportunity no matter where you are in your career, and I think as with other businesses like medicine, you know there's a lot that you can do with it, and and especially with podiatry. Even if you've been doing it for ten or fifteen or twenty years, you don't have to feel boxed in by by what you're currently doing. With a little bit of like creativity. I think you can really make it into whatever you want it to be.

Jennifer Spector: So now let's look into the future, if if you will. What do you see private medical practice looking like in five years or fifteen years down the line? Is there anything in particular that you hope to see, or that you think will definitely be there?

Alissa Kuizinas, DPM: So I think that more and more people are going to do the types of things that we've been talking about, maybe going into a cash based practice and relying less and less on insurance and less and less being managed by other companies. But I think that now people are kind of seeing that there are opportunities to get out of that, and to have a lot more autonomy, and I think most people that are doing that are finding that it's a lot better quality of life. So I think that people are going to continue to kind of go in that direction and show that, you really don't have to be solely at the discretion of insurance companies, or big hospital systems and things like that. You can really do a lot on your own, and and really make a a good living at it.

Jennifer Spector, DPM: Dr. Nguyen, What do you think the future holds for private practice?

Tea Nguyen, DPM: It's gonna get more fun because there's gonna be a lot of us who are going to see the other side of this right now. We know medicine is a big mess. We know that we're being asked to do things for free. We're asking, we're being asked to do uncompensated work after hours, and that has taken away work, life balance tremendously, and that has hurt a lot of us mentally, and I think the shift is going to be for new generations to see that life balance is attainable. You don't have to be in the clinic from nine to five, or for some of us, it was an eight to eight type of job, where we had to not only see patients, but we had to do administrative, we had to chart. We had to learn how to code and bill and those things, or we were doing call. These were the things that you had to do to to earn your kind of badge of honor, to be considered an an expert in what you do, and I think we are changing the definition of what it means to be an expert, and we're going to. We're going to live on our our own terms, and not what somebody else is going to tell us what it means to live our life. 

Jennifer Spector, DPM: That's extremely good advice and great insights from both of you. Thank you so much to both of you for your thoughtful answers, and providing this food for thought for our listeners. Be sure to check out this episode and other editions of Podiatry Today Podcasts on podiatrytoday.com and on your favorite podcast platforms.
 

Dr. Tea Nguyen can be reached at teadpm.com.