Janet Kidd Stewart

Harp music plays through the phone as patients hold for the office of internist Garrison Bliss, MD. Bliss is one of the nation's first physicians to practice in a membership model where patients pay for their care on a monthly retainer basis, widely known as direct primary care.

Visitors to his practice website are greeted by a graphic bearing just his last name, with the "i" in Bliss formed by drips that had fallen gently into rings of nearly-still waters.

This type of "bliss" isn't too common in practices nowadays, with the physician burnout rate rising to unforeseen levels. Nearly 63 percent of practice-owning physicians reported somewhat or very negative morale in a 

 by The Physicians Foundation. Overall, a majority, about 54 percent of all 17,236 physicians, reported negative morale.

Bliss, who studied philosophy and biology in college, and his staff saw their own stress levels going down when he first started using DPC in the late 1990s. Typically, DPC practices don't contract with insurers, but charge patients a flat monthly fee for most routine care.

"One of the first things we noticed when we started was how quiet the office was," Bliss recalls. "It went dead calm, and people weren't running up and down the halls. A lot of the stuff we used to spend time doing didn't need to happen anymore, such as prior authorizations."

Over the next couple of decades, Bliss built out the model, first in his own Seattle practice and then with venture capital partners, he spread it to other locations around the country. Today he cares for his own patient panel, about 400 people, most of them long-time patients.

"It's wonderfully comfortable. When I get called (after hours) it's often somebody I've known 30 years," he says, which alleviates the worry of dealing with new patients he has to screen as potential narcotics seekers.

With stress and burnout being a major concerns in practicing medicine, DPC is one option for physicians to change their day-to-day routine while reigniting their love for medicine.

And while the morale numbers are disturbing, they are actually better than in 2012, when more than 68 percent of all physicians reported negative morale, according to the same Physicians Foundation study.

Some DPC physicians do find that it replaces one stress with another, however. Internist Inaam Schneider, MD, based out of Raleigh, N.C., says the stress of running a private practice drove her out several years ago.

"I had up to 3,000 patients and seven employees and still found it difficult to make enough money to survive," she says. "I was extremely tired, maybe sleeping six hours a night."

Schneider also struggled to keep up with medical records and doing complete work-ups on patients in the allotted 15 minutes in her schedule. She says she had to see that many patients each day just to keep her office doors open. "You end up getting behind [on charting], tired and irritable," she says. "The physician is becoming just a referral specialist and there's no enjoyment in practicing."

Less than a year ago, however, Schneider opened a direct primary-care practice Raleigh and is working on a fellowship in integrative medicine, which she expects will help attract patients.

"You do replace it with another kind of stress in that you need to recruit patients, but this is much better," she says. "You have to put yourself ''out there,'' but that's my personality anyway."

Elise Fulsang, MD, also recently started up a DPC practice in Waikoloa, Hawaii after practicing as a hospitalist.

"I was coming up on 57 and the realization comes upon you that the 12-hour shifts aren't something that can be sustained long term," Fulsang says. While she now enjoys spending up to two hours with patients, she worries about whether she'll be able to build up enough of a patient panel to make a living. To set up her new practice, she has cut into her personal emergency fund. She also has the unique Hawaiian economy to contend with, including high prices for office furnishings and difficulty getting discounted labs and drugs for patients, she says.

"I'm no longer burned out, but I am scared," she says. To get the word out about her practice, she's given talks to a local rotary club and has made connections with vacation rental landlords about providing care for short-term guests.

For Lisa Larkin, MD, starting a DPC practice near her formerly long-time practice in Cincinnati, Ohio helped her get up and running quickly. After the first seven months, her practice was up to just under 800 patients in February for herself and two employed providers, a physician and a nurse practitioner. She's aiming to close the practice at about 1,200 patients.

"My two providers hands down will tell you the stress level is vastly better now," she says. Larkin originally sold her practice to an academic center, then continued working there until she tired of the bureaucracy.

"Of course, [her employees] have the security and I have the debt. But if you take away the financial pressure, the truth is professionals are passionate about what they do and at the end of my day I feel like I'm doing a better job than I was before. Instead of seeing 26 patients a day, I'm seeing about 16. I would stop practicing altogether before I'd go back to doing it the old way."

Clint Flanagan, MD, founder and CEO of Nextera Healthcare, a DPC practice with several locations, still runs a Colorado fee-for-service practice in addition to Nextera. He says his worst days in the DPC practice are better than his best days in fee-for-service family medicine when it comes to stress and overall satisfaction.

"You enjoy relationships with your patients and you are not wasting your time, and wasting time leads to more burnout than anything," he says. "It puts the physician back in charge."

Articles

Feeling burnout symptoms, physicians nationwide are changing their practice models to subscription-based clinics.

Physicians Find Relief from Burnout in DPC

After 11 years as part of a group family practice, Michael Iannotti had earned top marks from payers for his ability to demonstrate quality measures, but was frustrated that not everyone in the group shared his zeal for documentation.

"Physicians don't like all these new quality metrics, and the hospitals and government agencies that hire the physicians aren't good at it, either, so they end up losing a lot of money on employed physicians," he says. "I decided to create my own practice and participate proactively to get my quality measures to where they needed to be," he says.

Iannotti also knew that eventually he wanted to own his own medical building and didn't particularly care for the one he was practicing in, so the Lafayette, Colo.-based family practitioner decided to go solo last year. Not only did he go solo, but this fall he's launching a concierge practice in addition to his separate fee-for-service aesthetics practice.

More and more physicians can relate to the need for reinventing the primary-care model. In the most recent Great American Physician (GAP) survey, more than two-thirds of the 1,314 physician respondents say they would consider switching to a direct-pay practice that doesn't accept insurance, they already have switched, or are planning to make the change.

A year earlier, responding to a similar but not identical question, 43.2 percent said they were considering a direct-pay practice and 10.3 percent said they were planning to switch or already had.

The surge is exacerbating an already serious shortage of primary-care physicians in employed situations and traditional fee-for-service practices, says Jim Stone, president of The Medicus Firm, a Dallas-based physician staffing and recruiting firm.

When a physician decides to open a concierge or direct-pay practice, it typically involves slicing off a small portion of patients, creating a service void that either a hospital or practice must back-fill, Stone says. He says his firm has also been hired directly by physicians transitioning to DPC to find physicians willing to take custody of medical records and bring in patients not coming to the new practice.

"In internal medicine we used to have a third of residents go on to specialize in pulmonology or other fields and two-thirds went into practice. Now, the reverse is true and we further slice up the primary-care area with hospitalist, concierge, or other non-traditional models, so it's gone from bad to worse [with regard to the shortage of primary-care physicians]," he says.

Physicians working in these new models, however, say they are thrilled to be more in control of their practices, are making more money than in their previous practice or expect to shortly, and are hearing from patients that they love the change.

"I'm no longer beholden to the 'meaningless abuse' model of checking boxes" to fill out payer codes, says Denver family physician Michael Keller, referring tongue-in-cheek to his thoughts on Meaningful Use standards. "It really frees you up again to enjoy the practice."

At a July conference in Kansas City on direct primary care, hosted by the American Academy of Family Physicians, keynote speaker and a DPC family practitioner Julie Gunther noticed many attendees were physicians still part of traditional practices and only beginning to contemplate making a change. Typically, DPC practices charge monthly fees that cover most primary-care services and they don't take insurance, as opposed to some concierge services that combine fees and third-party payments.

So, during some downtime the first night of the event, she grabbed a microphone and asked two other DPC doctors to join her for an informal Q&A session.

"We had 40 doctors sitting there for three hours," she says. "We finally had to cut it off. There are some hitches in the giddy-up, but what we do is so simple and sometimes [physicians] are made to think this is so complex. It's amazing what you can do with a stethoscope, an iPhone, and a brain. And it's neat to see these docs have micro-epiphanies, realizing they can be the kind of doctor they want to be."

Though Iannotti's model is more complex, combining some aspects of traditional insurance payers, concierge, and direct pay, the sentiment of finding a more fulfilling practice type reflects his professional and personal goals.

"First and foremost, I wasn't satisfied professionally with my income or my job," he says. "I wanted life for my kids, my patients, and me to be better. I wanted money to eventually be able to send my kids to college, time to play a round of golf twice a month, and a better environment for my practice and my patients. All of that played a role" in his decision to start a new practice, he says.

For Gunther, dissatisfaction and burnout also drove her decision to make a change two years ago. While employed, she recalls one particularly grueling day when she saw 17 new patients. There was also the day when a trusted, highly skilled nurse quit to join a much slower-paced practice, and was later replaced by a very inexperienced nurse.

Routinely, the practice ran out of supplies that weren't reordered until she made a fuss. She even changed a few light bulbs in the office. Finally, she decided that if she was going to have to do all this herself anyway, she should take charge. "When someone explained that if I would just take insurance out of the mix, then I was able to see a path where I believed I could do it," she says.

Before jumping ship like Gunther, however, physicians need to be aware of some barriers to entry and some significant risks:

While many legal experts today say non-compete agreements aren't holding up in court, it can still take resources to fight the battle, says Gunther, who had to give four months' notice when she left her traditional practice. So first, realize the process of shifting gears could take some time, during which you may need to moonlight or seek some other temporary income stream.

Walking away from a guaranteed or RVU-based salary takes some guts, so being at least a little risk tolerant is essential, experts say. At the time she launched her direct-pay practice two years ago, Gunther still had about $170,000 in medical school loans left to pay. Today, that's down to about $100,000.

On top of loans, there is the common need to borrow funds to start a practice. Gunther was able to secure a Small Business Administration loan to buy her office building, which she's partially renting out to other professionals while she builds out her practice.

To mitigate risk if funds are extremely tight, she says, consider starting out small by renting space in a medical complex and moonlighting to supplement income for a while.

While direct-pay practices typically reduce a physician's panel size, they don't necessarily create bankers' hours. Most DPC practices strive to offer same-day or nearly same-day appointments, and many offer weekend and evening hours.

Keller, who switched to a direct-pay practice, Summit Primary Care, in October 2015, says he's on call 24/7 and schedules patients six days a week, including two evenings.

"The difference today is that I'm seeing six to 12 patients a day, not 30," he says. "It's much more manageable." He also says his practice growth rate was roughly twice what he expected when he started it. About 10 months into the venture, he had more than 600 patients, but says non-emergency after-hours calls are rare because patients typically feel they are getting all their questions answered in their office visits. Keller charges $89 a month for adult patients that are 27 and older, and $59 a month for younger patients.

Unlike Iannotti, Keller focuses exclusively on the direct-pay model, so he doesn't have to pay for any staff time to work with insurance companies. His wife, Audrey, works for the practice as a part-time practice manager and he employs a medical assistant who helps him room patients, among other routine tasks. When not with a patient, however, it is typically Keller at the front desk greeting people who come into the office.

"I've found patients really like that," he says. "You have to keep overhead down."

Gunther bought her office building and employed a second physician for the practice before taking a salary for herself, but says both moves have already paid off because the building has appreciated and the other physician is picking up the patient load she can't handle right now.

Meanwhile, she watches the smaller expenses closely. She purchased office equipment at discount retailers, for example, and counsels physicians who can't afford to purchase their buildings to shorten their leases from three years to one or two.

"There are opportunities to just hemorrhage money doing this,'' Gunther says, so take a pass on equipment leases if it's something you can purchase cheaply at a warehouse store.

• Detailed charting won't be left behind. 

Despite the considerable reduction in staff time devoted to billing third-party payers for services, physicians can't throw away those EHRs, experts say.

"I'm meticulous about charting and want complete family histories in the record, both for medical and legal reasons," says Keller. "But without having to worry about checking boxes on ICD-10 codes, I get a thorough note that clearly says what is happening with the patient."

Physicians switching to a direct-pay model need to be aware that fast growth doesn't always occur, says Gunther. "I had a business person tell me half of all businesses fail in the first year and that if you make it through the third year, you'll probably make it," she says. "So I tell physicians to plan for three years how they are going to survive if the business isn't profitable. Having that in place decreases the startup stress and the likelihood you'll scalp your mission to make more money, which can compromise you."

. She may be reached at editor@physicianspractice.com

Direct primary care practices are growing in popularity, according to this year's GAP Survey. Why is that the case? 

Why Physicians Are Embracing DPC Practices 

When it comes to investing, doctors are notoriously active traders. Who among you doesn't know a day-trading radiologist or an orthopedic surgeon who speculates in farmland?

John Kidwell, a Dallas dentist, was no different.

By his own account, he fumbled around with various brokers and financial advisers over the years. There were limited partnerships. There were oil and gas deals. When the tech bubble burst at the end of the '90s, he lost half of his savings.

"It seemed like everybody but me made money," said Kidwell, 65, referring to the advisers he paid along the way. After the 2008 financial crisis, he quit working with investment managers altogether, but didn't love the idea of a completely do-it-yourself role.

If the new realities of physician compensation and the old ways of dealing with investment advisers and brokers have left you nervous about having enough for a comfortable future, it might be time to look for a new path.

First, some good news: Just as online trading and discount brokerages cut transaction fees more than a decade ago, costs for broader portfolio and financial planning advice are dropping, even as regulators beef up the standard of care many advisers must take with customers. And there are more options than ever for choosing the way you want to interact with an adviser, whether that's over filet mignon at the hottest restaurant in town or in your bunny slippers at 4 a.m.

The challenge is finding the right type of advice while staying aware of whatever caveats come with your choice.

Today, Kidwell's financial advice team includes an accountant who specializes in private practice issues, an investment adviser who recommends exchange-traded funds and index mutual funds with rock-bottom expenses in his IRA, and a so-called robo-adviser, Betterment, for managing his taxable savings account.

Digital investment managers - from independents like Wealthfront and Betterment to industry mainstays Charles Schwab and Vanguard - hold a portfolio of mutual funds or exchange-traded funds, rebalance it automatically without involving you, and typically charge much less than the standard industry practice of 1 percent of assets under management, plus investment costs for a face-to-face adviser. Wealthfront charges 0.25 percent of assets per year, and Betterment comes in at 0.15 percent for accounts above $100,000.

Schwab has a digital platform that charges no advisory fees at all, though the company makes money on customers' cash and underlying investments. Vanguard and other services, including Personal Capital, mix in live advisers, typically via phone.

Mainly targeted to younger investors with modest assets, the digital investment world is beginning to branch into higher net worth and older customers.

Betterment, for example, which says a significant number of its customer base is 50-plus years old, offers a draw-down strategy for retirement income as part of its service.

Kidwell happened to be the childhood dentist of Jon Stein, Betterment's founder, and chatted up the startup entrepreneur about the service before signing on.

"I've had [live advisers] who held my hand before, and they panicked, too in market downturns," Kidwell said. "What appealed to me was being able to pick the risk I wanted to take and then not think about it very often."

Robos don't pump and dump stocks, trade rapidly to run up commissions or, go on vacation just when you wanted to talk about your plan.

The autopilot approach isn't for everyone, however.

"I wonder about the [robo-adviser customer] when he logs in and sees the market down 30 percent," said Andrew Sloan, founder of Bluegrass Financial Planning, a Louisville, Ky.-based fee-only financial planner. "There's tremendous value in face-to-face communications, particularly when you're getting close to retirement."

Beyond the hand-holding issue are other shortcomings. Most online wealth managers ask fairly rudimentary questions about your risk tolerance, for example. Particularly for physicians, many of whom get a late start on saving and have atypical needs for asset protection, that could be a problem.

And robot or no, some advisers won't or can't advise you on your total investment picture. If half of your savings is inside an active 401(k) plan, for example, a digital manager might not have the capacity to "see" inside your institutional investments in the plan. Or a live adviser might be unwilling to advise you on the 401(k) assets because he or she is only being paid a percentage of your investments outside the company plan.

So, how to find the adviser - human or otherwise - that's right for you?

Doctors rarely get too far along in their careers without being pitched or getting a recommendation for someone to manage their investments. Rather than hiring the first person who asks - even if you check the person's background - consider instead starting with creating a profile of the services you're trying to buy.

Are you looking primarily for investment management, or do you want comprehensive advice on tax planning? Are you getting close to retirement and wondering when to take Social Security benefits? Planning for your kids' college but still digging out of medical school debt and need help prioritizing?

For more comprehensive financial planning, a couple of websites have online directories of advisers, with either short biographical information or links to individual websites. Check out the National Association of Personal Financial Advisors (

Asking the same questions across a few different advisers will give you a sense not only of their communication skills, but also how their practice models work. Ask to see a sample client statement (names removed for privacy) for someone with a portfolio of a similar size and with goals similar to yours, such as saving for retirement.

As you review the alphabet soup of professional designations for each, be aware that some of them garner substantially more respect than others. Top designations include Certified Financial Planners, Personal Financial Specialists within the Certified Public Accountant community, and Chartered Financial Analysts.

Once you've narrowed the herd to a few top candidates, it's time to check out their backgrounds.

The Financial Industry Regulatory Agency (FINRA), an industry self regulator, earlier this year launched an advertising campaign urging more investors to use its BrokerCheck website (

). It also asked the Securities and Exchange Commission to require brokers to post a link to BrokerCheck on their websites.

While FINRA regulates broker/dealers, often called registered representatives, BrokerCheck automatically routes users who input financial advisers' names to the SEC's Investment Advisor Public Disclosure site. State securities and insurance regulators also maintain disciplinary records. Check out 

Make sure you understand the adviser's business model, advice offered and not offered, and payment schedule. Be aware that even comprehensive financial advisers can have subtle conflicts. Even with a fiduciary obligation, some industry observers have pointed out the potential for conflicts if, for example, an adviser who gets paid based on assets under management can be truly objective about advising clients whether to use those assets to pay off debt or purchase insurance.

That's why some advisers work solely on a retainer or hourly basis. If you're a higher net worth client considering working with an adviser who takes a percentage of assets every year for the same service he or she provides to clients with smaller portfolios, it's completely fair and appropriate to question the payment model and negotiate fees. Often, this conversation brings out the services your adviser truly provides - and the ones you're willing to pay for.

is a freelance writer based in Marshfield, Wis. She holds a bachelor

's degree from the Medill School of Journalism at Northwestern University. She can be reached at 

This article was originally published in the January 2016 issue of

Finding the right professional to guide your financial future can be tricky. Make it easier with these tips.

Select the Right Financial Adviser

Finding the right professional to guide your financial future can be tricky. Here are some ways to make it easier.

1. Don't search solely for an adviser who only works with physicians. You want someone familiar with clients like you, but you're more than just a physician. Say your spouse is a corporate executive with stock options or a defined benefit pension, or you want to blend your emotional values with your financial plan - there's an adviser for that. One example: Check out 

2. Ask to see a potential adviser's letter of engagement well before you intend to sign on the dotted line. Compare it with the other finalists. Does it acknowledge a fiduciary duty to put your interests ahead of the firm's?

3. If you're interviewing a financial adviser who is paid a percentage of portfolio assets annually, ask for a typical weighted expense ratio of the underlying mutual funds or exchange-traded funds used in portfolios. Then once you are a client and have designed a portfolio, ask again for your all-in fees and expenses in addition to the advice fees.

4. If you're within 10 years of retirement and envision working with this person ideally for the rest of your life, ask about his or her retirement income plans. Does he have one? Is it a ballpark rule of thumb, a robust decision-rules method or a computer algorithm-based strategy? The retirement of the baby boom generation has spurred a flurry of research on dynamic withdrawal strategies aimed to more surely survive even a very long lifespan. Make sure your adviser has a strategy for this.

Not all financial advisers are created the same. Make sure to do your due diligence before you commit to a working relationship.