DPC Doctor
Dr. Erika Bliss is a graduate of the University of California, San Diego School of Medicine. She received her undergraduate degree in History from San Francisco State University and a Master’s degree in Latin American Studies from Stanford.
She completed her medical training at the Swedish Family Medicine Residency Program in Seattle in 2003. After residency she worked at Carolyn Downs Family Medical Center in Seattle, an FQHC, where she served as a staff physician, Clinical Site Director, and Director of Clinical Quality
Dr. Bliss has traveled extensively in Mexico and Central America. There she collaborated with a local women’s health and human rights group to do research, including a video project, on domestic violence. In addition, she developed and implemented a medical education exchange program with a rural hospital in Honduras. While in medical school, Dr. Bliss was a founding member of the Free Clinic Project of San Diego, a student-run project that delivers primary care to homeless and indigent people. Not only has Dr. Bliss focused on direct patient care, she has also been involved in organized medicine and health policy through her work with the American Academy of Family Physicians. Additionally, she served on the education task force for the Future of Family Medicine Project, a national effort to chart the direction of Family Medicine for future decades.
Dr. Bliss served on the boards of the Washington Academy of Family Physicians, and the American Board of Family Medicine.
Dr. Bliss helped found and later served as CEO of Qliance, the first large-scale DPC organization in the US, started in 2007. After Qliance closed in 2017, she established Equinox Primary Care where she is a solo practitioner. She also volunteers for End of Life Washington, helping people who want to take medications to aid in dying to avail themselves of the Washington Death With Dignity Law. She has conducted volunteer forensic medical exams for asylum seekers since 2005. And since the beginning of COVID, with access to abortion severely curtailed, she has been providing telemedicine medication abortion services.
Outside of medicine, she is busy lately helping take care of her granddaughter and spending time with family, as well as raising her 1 year old miniature poodle, Shaytun, who she hopes will become a therapy dog in her clinic soon.
Dr. Bliss speaks about virtual DPC options at Equinox Primary Care - Hint Health Blog 2020
Dr. Bliss talks about DPC as a driver of innovation a the 2019 Hint Summit
Dr. Bliss talks about the Qliance experience at the 2018 DPC Summit
Dr. Bliss Interviewed by Concierge Medicine Radio
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TRANSCRIPT*
Welcome to the podcast Dr. Bliss.
Hi, nice to be here. Thank you so much for joining us. I just am so honored to have you as our first interview of the season.
And when I say that, what I think about is that you've really been there and done that and seen it all. You have gone from residency to enough QHC to working at clients, being CEO there, and then opening your own direct primary care at Equinox. So thank you so much for joining us today.
Now in the past . You had said a quote that I really loved and I wanted to start our conversation with that. And the quote was, and that's what primary care is. It's meant to adapt, to figure out and help the communities at serves. And so I was wondering if you could share with us what that quote means to you when you show up for your patients every day.
So that quote was really from my, some of my most important mentors going into family medicine. So really more specific to the specialty of family medicine, but talking about the name of the primary care doctor for your future. And to me it represents some of the best of the specialty, some of the best of primary care and reflects actually data from the rest of the world in other healthcare systems are primary care is the foundation that the health care system, fanatic community.
So that always really appealed to me. And then in family medicine, the training is so fabulous for walking into any community and adapting to it. That's really what it's all about. So for me, family medicine, and as a system and approach for doing primary care, which is a function in a healthcare system was the ideal So from early I was talking to my mentors and that's what I was hearing over and over again. And examples of that are, I work in a large metropolitan city in Seattle, so it's not like I'm going to learn how to do colonoscopies. We have a ton of people here who can do them. They do them all the time.
They're excellent at them. So I'm not going to do that, but what if I was a doctor in a very small community and the only way that people could get colonoscopies consistently would be, if I learned how to do it well, it's a procedure.
It's something that, as a physician or any well-trained healthcare provider, you can learn to do any procedure. It's, it takes some time and focus and all that, but if that's what your community needs to do, if your community needs you to do we've all learned about contact racing now, right?
Public health and epidemiology type of work, then that's what you do. If you have a heavy load of substance abuse disorders in your community, and you learn to work with people who have that. So to me, that's that wasn't specific to Deakin C. It was really about what are we supposed to be doing as primary care providers, whatever type in any community.
So then translate that to DPC. I felt frustrated with the system before I started doing direct primary care and realized that direct primary care by creating a rational business model would allow me and the folks that did this assumption in a way where we could adapt what we do for the community.
So you could, whoever signed up for your practice, whatever populations you ended up serving, you study that and observe and research it and figure out what to those folks. It's just, it's a hundred times easier for the proceed because you have control over how you spend your time and resources.
Absolutely. And I think that it's such a Testament as to why this movement is growing and continuing to grow like wildfire because we're not cookie cutter doctors and we are not working with cookie cutter patients. And so the ability, like you said, so eloquently to learn and to, you know, study about your patients and then to deliver that personalized care every day to your patients, it really is so different from every 15 minutes you have a new appointment.
Yeah. Now I would really love to also have you touch on your experience overseas because clearly you were so involved working overseas in a health setting. what of your experience there, have you also been been able to bring back to your practice at keylines, but also, especially at Equinox now.
Yeah. So probably the most influential experience for me. And this was a big part of what made me decide I wanted to go into medicine, was working with the women's domestic violence and human rights organization in Southern Mexico Javis. I went there as a graduate student doing Latin American studies or the background in history, looking to volunteer with them and write my thesis about their group and their movement, because it was so striking that such a progressive and incredibly well thought out program had developed in this pretty remote part of Mexico, or, it's a big travel destination, but it's a very conservative part of the country.
So I interviewed all the people working for the organization, all incredible women and activists. And funny enough, the doctors ended up capturing my imagination more than anything. And I. Healthcare was a really interesting way to access a community and sight out what was going on. You have this very privileged view into the private lives of people in the community that are, it's hard to get.
You have to be like the priesthood adopter and hear those kinds of stories. What really struck me about the doctors too, is two things. One was there really very well developed concept of public health, community health, and empowering communities to take control of their health. The other was their incredible humanity in dealing with patients.
They would see women who had never been to a doctor before who had been sexually and physically abused. Many of them had terrible reproductive health problems that were never getting dressed. So this was their first time and I just sat in the room with them while they did these interviews with these women.
And I was so impressed with their, they were so relaxed first of all, and it was we can take all the time with me and when you want to stop the stuff and you can always do another appointment. So there wasn't this concept of, I have to meet my metrics. This woman needs a pap smear. She might have, cervical cancer.
I got to get it done. Now it was more like, I need to gain your trust to review this at your pace. And they were very well informed about, they were doing the Thomas, focused approach to women's healthcare and, general mental health care long before. And this was 1992, basically that I was down there working with them.
So way ahead of where we were. So that really struck me and it planted a seed. So when I went back to school and I realized I wanted to get involved in health care and I told people, here's what I'm interested in doing. They started suggesting to me, why do you become a doctor? And literally that was how I started to percolate wow, doctor, and started that whole path.
So that had a huge influence on me. I was just so impressed with what they were doing and I felt like they were so far ahead of so much of what we were doing to do that.
For the people who are listening to this podcast, especially if you're in medical school or in residency, and you do have the opportunity, or even if you're a physician who is able to um, you know, have the time to take a trip overseas, to work with organizations.
I mean, Yes, it's a little harder with COVID, but at the same time, there's so many ways to support overseas organizations. And I truly believe having done overseas work myself. When you speak to. Your experience and how the setting was, where people really have the trust in you, because you're a physician because, you know, you're there with the understanding that you're there to take care of them.
When you talk about the relaxed visits, it's like, when, while you're talking, I can envision myself in those same visits in the Dominican Republic or in Ghana. And other physicians have talked on this podcast, Dr. Jack Ford, Bush, Dr. Christina Gonzalez about time overseas.
And so I encourage people to, if you haven't and you have the ability to definitely, think about having that on your horizon in terms of checking out a way to serve another country and another, another community, because it really it really brings a different perspective to your life, into your way of practicing medicine.
Two comments about that. I, to add. I think it's really important when you go overseas to see the healthcare workers that you're going to be working with and observing and all that, seeing them as colleagues and really approaching it as what a great opportunity to connect with colleagues in another country.
I think that is much appreciated by them when we did our exchange program with this community hospital in Honduras. It was really cool because we set up, we wanted it to be an exchange program. So we were going to send students and residents down there, but we wanted to, we were adamant with UC San Diego, that we had to have the opportunity to bring up their doctors and nurses.
And so we got funding for it and all that. We managed one trip for them to come up here. It was so you're Craddick and difficult to just get them into any facility to even observe. It's just crazy. But we managed to do them. Week one was a surgeon. We paired him up with some surgeons and he was so delighted to be able to connect to his colleagues here and vice versa.
They loved it too, because we always have stuff to talk about oh, what are you doing? He asked me for that, oh, it's this gadgets, same with the nurses. That was really neat. The other thing I'll say about it more related directly to DPC is that it's so important. I think, to recognize what can be done in less resource intensive environments, because so much of what we think we need to provide health care is completely unnecessary.
And especially if you're going into DPC and setting up your own practice or working with people to set up. It's easy to get overwhelmed and think you'd have to have a whole lot of complex stuff and a lot of machines and like sakes in every room and all this stuff when you really don't. And I always remind people that talk, I heard of with doc in them new Orleans after hurricane Katrina, and she was saying, look, we had to do medicine on the street corner.
That's all there was. People need to care. So I always read that. Remind myself of that. And obviously if you hang out a shingle on a street corner to come to you here, but it bonds you that realizing, okay, what is it that people really want to need again? How do I respond to my community?
What's going to resonate for them. And that's going to be time, very poorly compensated in that.
Definitely. And I love that. I love that. And it really again, just going back to the fact, this is the opening podcast for the season. It really challenges people to think about that, especially if they haven't yet purchased their first and a meds purchase or at least a space.
So definitely things to think about. Now. I want to ask this question cause I love asking everybody, but and you alluded to it earlier that you knew that there was a better way to do health care after you finished residency. But how did you come to learn about DPC?
So I actually had the privilege of being related to somebody's PC.
So my cousin Garrison bliss, the granddaddy, his direct primary care was practicing in Seattle. And I just happened to pick a residency in Seattle. So it was just gives me, cause I really didn't. I had never really spent any time with Garrison. We've lived in completely different states growing up.
You know, A generation older than me. So even though we're cousins he had, much further along in his medical career. So he was practicing with his it was called concierge at that point before the name was invented. But it was so great because all throughout residency, periodically we would get together and I'd come over and shadow him in the clinic or we'd go out dinner and I'll never forget.
Anyone who knows Garrison knows he's like Mr. Happy all the time. So there's a reason for that. He quickly, he got out of the increasingly stressful rewarding world, thinks of service and leader in general silo kind of hair and moves into doing this McKinsey model and found such joy in his practice that he just, it kept him the, bubbly, happy guy that can cause that.
So imagine you're a resident, you're kind of like, oh, well, I'm tired, they're having a bad mood and everything has way too much to the year. And then you're following around this doctor who didn't last. So how does it feel to be this kind of macros? And he says, oh, every time I walk into a patient exam room, I feel like I've been invited to a party.
And I was like, oh God, this is one of the crazy blesses. But you know, He really, he just would drop these pearls of wisdom all the time that I go running back to the residency and meet, our balance sessions with the other residents. And it's a Harrison told me this time, he said, he feels like he's been invited to a party.
Isn't that amazing? And or just little bits of really great advice, people going into DPC we'll hear things like how are you going to deal with the worried well or super anxious patients and all that kind of thing. And he said things like, if someone.
Always anxious, it's ours, or I guess like over utilizers, that's what people will say is that term. And so I've thought that too, like, how do you deal with over utilizers are gonna eat up all your time. You want it to answer anybody else? And he said, there's no such thing really, as overutilization, there's a reason why someone is to see the doctor all the time and calling all the time, because throughout who would in their right mind, want to spend all their lives through knows the doctor, it just is not a healthy, normal use of your time.
Right? Our health should be, if it's ideal, it's great. And it's in the background and we're living our lives. So he said, my job is to get to the bottom of why that is. And is this person suffering from anxiety disorder or do they have some UN recognized fear that hasn't been addressed?
So many, I could tell you a million of these. So many of these really stuck with me. And I thought about doing this kind of practice that in medical school, when he first started doing it, I learned about it, but, and I thought Rocky did this for Medicaid. And I think we do this for everybody.
And it really is quite affordable the way that he used it. So I really was intrigued with it, but I couldn't imagine nobody at that point was coming out of residency and setting up their own practice. There was really no modeling of that. And there was no mentorship available and none of us could imagine science and something like that.
It just seemed so overwhelming. And a lot of folks, including I had some debt, I didn't have a lot from Philly. You come out of training with a bunch of debt. It's not like you're gonna take on more debt to set up a package. So it took a while, but he, and it hurts me it from years into my practice of the FQHC narrow downs and said, Hey, I'm thinking I want to do this on a larger scale and you have to join me and, lots of back and forth.
And eventually I said, And that was the birth of two lions and clients in the process of working with Washington state legislature and the insurance commissioner to make it legal, which was cracking me up. Cause it's it's just a business. Why does this have to be given the blessing of the missions tradition work?
But we had to come up with a name for the model. And during that registered session is when we made up the term direct primary care. So that's where it comes from. It wasn't all that before that. So a little bit of history for everybody, but that's how I got.
I love it. And yeah, that's not just, how did you learn about direct primary care, but you just shared about how the movement was named.
I love that.
That's awesome.
And for those who have not yet checked out Dr. Bliss's blog accompanying this podcast, there is a recording where she goes into depth about the experience at Carolina. So I definitely encourage you to watch that recording from the 2018 DPC summit, but Dr.
Bliss, can you give a high level introduction to those people who might not be familiar with Q lions, what Q Lyons was and what an impact it has made on this entire movement
sure. So the dream of TLI is, was to demonstrate how this model actually could be the.
The models of primary care in this country and repair so many of the problems that were plaguing it. And bottom up repair a lot of kind of re rebalance. The healthcare system drives really good incentives. Drive better care, bring the majority of the care back to family care, which is where it belongs.
So, you know, In a whole bunch of different studies that have been done, it's been shown that 85 to 90% of what people actually need from the healthcare system can be provided in a primary care setting. Especially if you have pretty robust capabilities. But our system is flipped upside down and we can primary care so much that we can't do that.
So she Alliance wanted to demonstrate how effective this would be. So we set out from the beginning to, to prove it's a prison onset. So we looked at it as Garrison's practice was like the beta and this was going to be the best for real, as it turned out to Elias was the beta for beta gamma. Now I'm like terrified of things, Greek letters, but anyway we figured we would start reaching out to individuals.
And then later we realized we really need to engage with the system that it's built. So instead of reaching out to employers and ended up building seven clinics and the Puget sound. We had a wide variety of customers. And the employer business became a big part of our business because employer sponsored health insurance and health coverage is such a huge part of this country's system.
And you really couldn't operate outside of that entirely. We also ended up working with a Medicaid managed care plan and right about starting about a year before the ACA going into effect. And then when the ACA went into effect, it became a massive program. So it's covering both Medicaid and exchange department members.
So we, you know, grew and grew and grew and grew. And we actually really got exacerbated the ACA, which was very challenging. But we were able to event it's very, very painful process, getting the data downstream to be able to show what we were doing, but we did end up being able to show that this model of care almost naturally, by the way, it was set up, drove much decreased use of downstream resources, and we never set any rules or restrictions on any of the providers saying we got shot, not the sir.
We didn't really give them feedback on their refills. Like saying here's your benchmark and you're sending too many referrals and it's costing too much. We just did an actual experiment in that. And, the minute you cut that, I mean, a hospital stay is a minimum it's $2,500 a day. So a room let alone all the care.
So if you prevent one, hospitalization it please for months and months and nurses, direct primary care. So it was great to be able to demonstrate that, and then in a Medicaid community population, to be able to show that it was very rewarding. Unfortunately, we ended up getting cut off at the knees for various reasons.
And if you watch that presentation, they want more information on it. So I won't do that next here, but what I think happened in some ways is we stepped over a couple of wines that were sacred in the health care system where there's this sort of agreement among, our government and insurance companies and employers, everything.
to keep it the way it is. And so what we were showing was pretty radical and it really started to get some national attention. Funny enough, after the time article came out was it was very shortly after that, that the making managed care companies started to turn. And all of a sudden they were showing us data that shared that, oh, you did a terrible job.
That really is all they had. They had miss analyzed their own data. And when we said you're doing it wrong, here's the way that you need to actually look at the data we just got nowhere. So that was the beginning of the end for team orients because we had become that had become such a big part of their business, but, looking back, I'm really proud of what we did.
I think that, it was rough going a lot of the time. It was very different. And it ended very abruptly and painterly. Sorry, we've everybody. But I think that I didn't realize what an impact she lines and have really on the DPC community until the couple of years went well from 18. I guess it was a year later I went to the hint summit and I couldn't, it was like back to your smartness.
So many people came up to me and saying, thank you so much for everything you did to pave the way. And it was really hard, but it's been so valuable and it just blew more. And it really was the beginning of healing from that whole process for me, because I realized, oh, this is just the way movement stuff.
Right? And people have told me that at the beginning I had, we had investors and other people weren't I think they'd say to me, you know, Erica pioneers always get killed. And I was like, no, we're going to be different. I swear. I'm determined. And I had always been able to succeed when I was determined to do something, but this was my water would work, was like, actually.
Just being a little tiny company, determined to overturn the healthcare system, thinking it takes a while to build that kind of music. But and that's why I'm not talking about 10 only three lock it's break a lot of machinery and doing that. And we were sending engineers anyway. I was able pull the focus back and see when you're building or movement.
In retrospect, you look back and it looks amazing. Like it just unsettled and kept moving in this positive direction. But the reality is that there's a lot of pain and suffering along the way. There's a lot of missteps. There's a lot of, going the wrong direction having the correct.
So to me to see how many people have been decreasing now and how many people look to clients' experience for grounding in all of this is just amazing.
Absolutely. And even though that recording was done in 2018, the tunneling through rock session it's really evergreen content. I In that blog, there's also a concierge medicine radio interview that you did, I think 2014, but still the tenants that you talk about, the things that you're sharing today as well, this content is continuously going to help fuel and remind people of the value proposition that we bring as physicians to the table when we choose direct care.
So I love that, and this is why I think it's and I go back to that statement that you've literally have been through it all. You're this Phoenix in my mind you went through Q lions and the lines continues to impact the community, but then you also opened up Equinox primary care. So I wanted to, to touch on your practice now with all of these lessons that you've learned along the way and how you're operating your own solo practice now.
Um, I wanted to start with first asking, how did you choose the name Equinox?
So to Ryan's neck and shuttered stores, literally overnight, it was a big drama a big one that was about to come through and then, it just was taking too long and it came with this big and held back Medicaid company and then fraud committed on us.
It was just a disaster. It's it means like sound novel. And so we literally have no money to operate and it was very setting. So we're going to shut our doors. Bam. And I needed to work.
I needed the financial means to pay my rent and keep going. So. I had to get super fast. I literally decided on the name within a day.
And I thought about the fact that I was going to be going through this enormous transition. And I thought about the equinoxes and how in human history, they represent such a major time of a year. And there's so many rituals around things. And it's this incredible explanation of new server from wiring, you know, kind of a darn stage, should a life stage, a lot of the dormant or whatever.
So it spoke to me in a sense of being this is going to be a major life change and I don't know what's coming, but we're going to see. Fantastic.
And with you being the solo doctor at Equinox, do you work with other staff at your clinic?
I do. I have one medical assistant and she actually, we worked together at Lawrence and she graciously agreed to continue working with the you and really has been our rock through this whole thing.
He was very devoted and supportive and I told her, I don't expect you to do this forever, but if you would help me get through the next year or two, and now it's been almost five years. She's been great and she's about 80 to 85% time. It varies. Because we really only are in the office or in person in the office before this.
And then we have an administrative day and typically she doesn't work on that day. Sometimes visit, but, and that's it, that's all the staff.
Gotcha. And in the past you have spoken about how, as you grew, having more staff added on, but it was. It was not necessarily a challenge, but it was something that you had to pay attention to while hiring that you had people who believed in the model.
So you, you definitely had a an advantage with her understanding what direct primary care is. But if other people are looking to hire staff for their clinic, if they're adding their first staff member or they're adding their sixth what are some words of advice that you could give to people who are selecting and weeding out those people who might not understand the core of what we're doing?
Yeah.
So I think it depends a little bit about how you set up your mind in terms of, I think one of the most important things is technical skills and professionalism. That's true of any healthcare setting when you don't work to me. I don't want to put anything inside of that. Those two things.
Because you can't really do mediate somebody who doesn't have a good sense of professionalism and can't you can teach skills, but you really kind of worked hitting the ground that you've got somebody who can do the skills and the technical things that you've been making work that now they're gonna do the kitchens and job lab and do all that stuff for yourself.
Great. Then you don't really need a skilled person, but in my scene, our play in the beginning, but then once you grow, it gets to be a bit of a distraction. The other thing too, you want to do, it really depends on if you're doing a solar, a mobile clinic, 50% mile probably don't want to pay to someone who dug around, but that's another.
So those things are at the top. I do, I would want to do it. And to me, it was important too, that I wanted to continue the way we had Dominic Alliance, that people who are licensed. Medical providers would have proper training. I don't think anybody, so that's number one. you know, one of the things we eventually put into the contracts to clients were things like, I agree that while I'm at work or on duty in some way that medications needs come before mine.
And we decided to make that absurd because we learned in exterior that people understood that's what was expecting. We're not asking people to tell themselves to patients for remove all boundaries and enable people or anything like that. None of that would assist this notion of, again, it's a, it's a concept of medical professionalism that when you're on duty, the patient's comforts.
And if you're tired of seeing Carnegie or whatever, emotionally get out, or uh, you know, distress if you can't function and take care of your patients, then take care of her business and then come back to it. But. That's given, it's think for folks, but we felt like we wanted to sit down. I think having somebody who's really personable who's, didn't answer the phone and be pleasant if people are in is that I frequently hear, which is really the patients there's lasted and so awesome.
She has a great way of putting patients at knees. She laughs about things with them. She really gets to know them. She has a very nice manner on the phone. She's just a great human being, so that means a lot. And one more thing I would say is somebody who can feel that you can need throughout the year.
And managing people is. Definitely was I've learned skill for me. And I can't say that I really loved managing a lot of people to clients that was very difficult for me. And I realized that there's definitely no bathroom there. And there's, doctors are not generally get good at it. You have to learn that set of skills and have done a philosophy of it.
Just like anything else you would approach managing people is not like it's people are breastfeeding or breastfeeding is just going to come naturally. Yeah. And it takes time to get good at it. I think managing people is similar and there's some people managing people is the worst possible thing to do.
And so maybe you shouldn't have staff or you should have a service that you use and have somebody else manage that. It all depends on how you want the coaching. So lots of different things to think about, but those are the main things that I had found to be most.
really great tips, especially for, , those people who are considering hiring staff,
When you opened your doors at Equinox, how was your panel?
Did you start with zero patients at day one and then grow from there? Or what was your experience after you opened?
So I was fortunate in that I had a core group of people to start asking. Honestly, nobody had needed care at that point. And I could get a little bit of money together and leave town and go to Mexico, just do great on a beach.
I probably would have done that. It was more, I had a bunch of patients immediate care, and so I set up to respond immediately to them. It was a little crazy, but I had probably about 180 people to start. But I had their records and I had all that kind of thing and I've had the assistant helping me.
So that was a really great starting because then it's you've got right. And you've got a nice stable base that you can accept a girlfriend. So that was kind of neat to come over and I was practicing.
I want to ask with you having 180 on day one, what was that like to manage everybody and to get them scheduled appropriately so that they got the care that they needed in a timely fashion.
So it was even more challenging than that. So key lions had a program with the Seattle firefighters, union health care trust, and we were doing a ton of firefighter physicals every week that we had staff doing that at a special clinic, et cetera.
So I said to the trust we can keep that going. And initially I thought that some of the providers come and do those with me, but they ended up deciding not to. So I was doing Catholic time doing firefighter physicals because it is a long involved physicals with doing almost testing and then halfway through my other patients.
And then shutting everything down for two hours. And so it was insane time. I don't really remember a lot of this huge word, but in a lot of things fell through the cracks. It was not an ideal way to start this, but it was out of necessity. And I felt a big sense of responsibility to try to maintain something
So essentially I probably, I have more than say under new patients that the other, the firefighter part of it was just who's physicals, continuous family. How do we manage it? It was very hectic and we were running back and forth between that location and a very temporary, small space that we had and looking for a new play eventually to settle.
But somehow we managed and the patients were so amazing. They were so understanding. I had a couple people schedule an appointment just to come in and check up on me and say, how are you doing? Are you okay? Is there anything I can do to help you? And I said uh, come see me. And they're like, no, I really don't need anything.
I'm just, you know, and I was blown away by that, that they cared so much that they cared about the relationship so much. And they wanted me as a doctor and that's to him check on me. So that was a very interesting space to have that. So I think it's interesting now. So I recently had another doctor during me in those days.
She has her own. Director of your practice. And she was very nervous about not growing fast enough. And I said, just, you just see you just wait and see, because a lot of people are going to follow me some that their back is, and the word is going to get out really quickly. And sure enough, she swooped up to, I don't know, like 85, 90 patients in the first in the market, a house.
And it's a little hectic. She's really having to run pretty fast. It's about that. And also that's onboard a lot of new patients. So the onboarding process of a bunch of new patients I've never seen before that is extremely time consuming. So it's interesting watching her go through it and I keep reassuring her and saying slow down.
Don't worry about you've got rather than right. If you're even just covering the expenses, that's fantastic. Just, you got time to do it right from the beginning. You're going to enjoy this a lot.
Definitely. And that idea of keep your overhead low is echoed in so many physicians when talking to others about starting out DPC.
Let me ask you there, when you looked for your space after your temporary location, did you look for a space that was including like a larger space that could be rented out to help make it easier for another physician to come join and use that space for their DBC?
So this face I would have liked the smaller space. I really didn't need all that space, but there wasn't a lot available. It was mostly bigger than R and you know, you can space pocket the Talkspace pocket, the space and not pay the rent on that portion of the space.
If you don't really need it and work out deals with ambulance where you have such strategist diesel to the additional space, or, if they choose to lease it out. We did that once or twice in two lions when we weren't parking enough to take the space, but were not going to go into it. So there's things you can do like that to negotiate with your landlord.
But I just didn't have a lot of choice and a lot of buildings don't want to do medical office space because it's a lot of costs to build it out. And then you've got this very chopped up stool. It mostly has to be taken apart. And this, we find another medical office space is by necessity. Very, we've got a lot of renewables and it's very closed up and most offices, other kinds of businesses, don't worry about that.
The other thing is oftentimes you're pouring money into a whole bunch of things, which is very expensive, also necessary. And that's the way I wasn't like that. So there were very few places available at the time. And healthcare, I don't know that healthcare providers are considered such a great option for landlords either.
So basically what I was going to get. So the building space designer came up with, I told him what I wanted and he said we've got this much space. Here's what I can give you. And beautiful design with his very first. But use it. So I tried renting out space to a physical therapist hypnotherapists at one point and knew that it was going to be this interesting thing where I've had other sort of alternative types of providers in that same space, but that really didn't work out to be anything really big.
And it was hard to find anybody who was going to be appropriate for this space. So the person who's in the space with me now, someone I've known for years and cast it and gradually move more and more towards care and considered a whole bunch of options and realize that, trying to improve the out space that's going to be
But get along with each other. It was his idea. I hadn't had that opportunity. I had been delighted. In retrospect, I realized I really could have tried harder to find space within another medical office, but again, it's a very frenetic time. It was, I didn't have a lot of time to really do the research. I didn't have the peace of mind in the calm to do it in the right way.
So I think another piece of advice I would give is there's a lot to be said for being centered and strong in your approach to setting this up and not allowing you to come to me for full custody. I got to make this decision the more of the way, give yourself a more lead time, not to doddle and think about things too much, but to be able to really approach it very methodically and some food options and talk to lots of people is a better way to do But I'm very happy with this face.
Patients really love it. It's not in a medical building, which is also very nice. That was great during COVID because everybody wants to go into any medical facility. Right. And I didn't see a lot of patients in person, but when I did need them to come in, I said, listen, this is not a medical office building.
It's not sick people going in and out. It's going to be one person at a time. Not a, the clinic. Pretty much all these businesses are working from home anyway. So there's literally nobody in the school, so it was very safe. So that actually worked out.
Thank you so much for sharing that about your space. And I definitely would say, especially if you have the ability to reach out to other DPC your area definitely reach out to them to discuss, you know, if they have a space, how did they come about their space? Because like other physicians have shared, there might be a realtor that they use who was very knowledgeable in negotiating contracts or you know, things like that to help you find an ideal space
and that's so important in terms of when you feel like you're being rushed into something, I definitely would say it's important for anyone to pay attention to that feeling and really work out where that's coming from. Similar to how you talked about Garrison, finding out like where the anxiety comes in patients when they when they contact the doctor all the time.
So important. Now you have a full panel. So how do you. How do you look back and say, okay, this is how I knew I was full.
No I got to, I grew a lot during it and I think I heard some other DTC practices that they did as well. And so various reasons I think we could see our eyes, that was the case, but I I grew by probably a hundred patients almost in a year of COVID that was, and I didn't really realize it at the time.
And then when I looked at my numbers, I was up really fast and I felt it right. So it was all of the stress of COVID and arguing argument saying and it definitely selves that I felt pressured. So when I got to about 440 patients, I realized I've got enough. I can't take any more concern. So I posted the.
And also by that time I had taken on a couple of other activities. I taken on a new activity attempt to talk about when I was continuing to do a couple of other things that I do on a volunteer basis. And the need started to really increase for them services during the COVID. And as I started got quiet a little bit with taking arm, that activity, that exit, once COVID had started was doing medication with patients by telemedicine and there that being this skirt Mendez meeting.
And there was a lot of work to do in conjunction with a whole bunch of people in this country and internationally to get that off the ground. And so I was really excited about that and got really involved in doing all this stuff. And he, while I didn't really notice him, the patient population was growing as fast as it was.
And it's someone that this was like, whoa, this is going to be a bit much on top of that, that all of our emotional and psychological and physical illness. Kind of COVID and all of the other sort of off the wall, social ethical, environmental evil, it's been such a Patel, anybody listening to the basketball part of it, what an intense time.
So I realized when I was feeling a little C stress, I was working on weekends consistently to catch up. My days were going along. It doesn't mean any office on, and I was getting irritable sometimes. And those kinds of things, those were all my signals that have not gone too far. And so I sat down and I thought, what am I really enjoying doing?
And I was like, I still know me. I mean, I really enjoyed finding the kids. It's a tough time to do it, just because everything, everyone wants answers to everything and it's all processing. We had just but I realized I really loved doing the medication abortion. And it was very grounding because it was such an immediate service and it was just like boom, boom, boom.
You know? And it was to serve gratifying, keeping her so grateful. It was just an incredible community that had gotten involved in. So I said, yeah, I'm going to make sure that I carve out enough time to do that and send them in some sense to do. And I also want to learn final notice. I'm 54 years old.
And as soon as the study, when you took the two, I said, darn it. I want to learn how to have balance. I want to focus on family. I want to do other things. I want to feel the fresh air. I just work all this other stuff that I never took the time to do or develop. And I've always loved working. I love my work, so it, wasn't hard to just give her that time for that.
That's when I really said, you know what, I'm just going to let it dwindle because of course many stopped taking patients to notice or to move people down. A lot of people died in various different reasons, not the pivotal in my practice, but probably people, people had about cancer, all kinds of stuff.
And so people moved away or, got some other coverage and decided . So I've let it Windle down to just a little over four, 400 now. And that is, that feels good. I'm I just watched yourself during that process to see, like, why is it that I start to feel like, okay, my schedule still has openings all the time.
I don't feel stressed. I can take time off during the day to go do other things. And the premise for myself, my mindset, high supervision, but get this go therapy that I needed, it was like, oh, it's not a big deal. If I carve out two hours of the day to go take care of myself or go meet up with a friend that I haven't seen him.
Go for a walk. I got a dog, right? So I need to train my dog. And I was going to say, so I don't want to be working till Saturday at night. I want to finish at six. We are, we see patients from 10 to six. I'm not a morning person set it up. So a bit of extra money and sensitive. So those were all of the things.
So now sometimes I have a week where I'm like, God is nothing on schedule. Maybe I don't have enough patience. But then I remind myself, I saw the same number of patients that are used the same. And it's going to pay back. This is this four week, wait a couple of weeks, inevitably, it's going to be an ever busy and crazy
So those are all the kinds of things that I looked at and I've really paid attention to my mood and my emotional response to things. And did I have the time and energy to stop and think about what I was feeling and to remain really engaged in right now. The dialectical relationship between myself and patients, myself and my staff and myself and my family to make this, we have an interesting time with those rather than just
It makes me think about when Dr. Jalon Burton and I were doing her interview. She told me how she has to put specific time on the schedule to network with other DPC physicians. And I was like, I had never thought about that and then I looked at my schedule and with this podcast, and just with talking about DPC while planning my own, it was like, I realized how many hours are spending just all over the board with networking conversations.
And being friends with the idea that you have autonomy and that you have the ability to look at balance and figure out what that means for your life. It's. Such a different place to be compared to in fee for service when you are, you know, you're here at these hours to these hours and then you have to chart in your pajamas and then you barely get sleep, et cetera, et cetera.
So it's so important for people to, to think about in their own practices when they're growing and when they decide to stop their panel growth.
And I schedule everything and I put things on the patient schedule, we've, we have this really nice system. And I think, we can talk about what systems I use it for black, but they're really nice to sit that makes scheduling.
And shuffling the schedule is so easy. And so I can honestly, I block out some time and where I can do it ahead of time. And it's easy to put stuff in and out and block out some catching appointments and all that kind of stuff so that I can create flexibility on the slider. I can also go ahead and I've gotten much more confident without just taking time and scheduling it out and doing other things that aren't just fine, but get the patients taken care.
I almost never do. And I'm not able to see a patient when we think it just always seems to. I think if of being at the right number is what burns to the patients and promise same or next day, they're honest that, you will be available for anybody to give is available for non-urgent things.
And then we've been at the clinic on the weekend.
So then the question is, are you meeting the expectations you've set with your patients and if you're not, or if it's a struggle to do it, then you need to adjust something. You have too many patients and we set the wrong expectations and that's changed. I promised a lot more to my patients that I needed to.
And then when I realized that they're not really using the surrogate stuff, and it doesn't mean anything to them, if they never need to access that particular aspect of the service. So why aren't we going to do it? you know, Setting clear expectations instead of getting angry with people because they bothered me on a weekend, put up, there's something that
What is wrong with this person? Why would they do this? I realized I had saboteur petitions that are always available to you, whatever you need, just contact me. And so of course they did. And then they were surprised if I was unhappy and I had to sit back and say them, it's not going to fall, but tomorrow I set up along the took them.
So that was a really big piece of ghost for me. Is that when you just tell people what they can expect of you and you watch yourself to make sure they're meeting those expectations, most of the time, give yourself a break. If you don't, it's not worth it. People are very happy with that because they know exactly what to expect.
Absolutely boundaries are so important, especially when you like yourself are a solo doctor, when you don't necessarily have, multiple layers of staff to deal with patient questions and patient refills, et cetera, et cetera, before they get to you. So it definitely is so important to keep in mind.
If your expectations or your boundaries that you've set up for your patients are that they have access to same or next day care. That could be in the form of I'll send you a portal message or an email or a text or whatever it is because it's still care.
It's still coming from you. So I want to ask, because at you guys did not have what we have now with all of these multiple EMR is to choose from and ways to communicate with patients.
So what tech have you found really, you know, hones in, on your ability to provide care for your 400 plus patients?
Yeah. You hit it right on the head. When I think back to our experience with tech and clients, and we opened in 2007 and, Garrison used to say, we should just build NDNR and everyone's you're crazy.
I'm like AMR. Anyway. So we ended up with a commercial EMR that really was, did not do what we needed it to do. This thing was funky and it was probably one of the better ones and more accessible ones, but also the expensive. It's funny. If you look at Paul tat and you say of course it was like that.
That's where it wasn't just healthcare software. Just, wasn't what it is now. Pretty much have the same expectations of it. Healthcare was further behind, but there, they, it just, nobody had what, so I really appreciate within their current, because nobody had what we really needed and we were super frustrated about it.
So we ended up actually building, we started with a piece of software that had been started to be developed with the diabetic and he was brilliant, but it was quiet ordeal that I actually think that will be built, whereas it was essentially a prototype. So what I could do would have been a really great system and we thought through all the workload issues and all the data that we need out of it, and I would've loved to really be able to pursue that.
Eventually we have to see lines pillars. We didn't have the opportunity to do so now. And I'm not a paid sponsor of any of these companies that I won't tell you use. I want to think of them. So I ended up, I needed to put something together fast. Again, the theme of mindset was fast. The first thing I did was I called up, Zach wants, goes, it can't.
Zach and I had met each other from the beginning. She was so wonderful, but I can't speak highly enough about it. And he's just such a great guy. And I had informally advised him as he was setting up tent. We would talk all the time. He was very attentive to me, to everybody in, to do the significant, and he puts a really nice piece of software.
So there was that question for me about, and in fact, it's dangerous. So then I and I didn't even know how to set up the website and Zack walked me through it and we were like chopped job in a couple of hours. I had a website it was posted, it was the happy with the Laredo system using anyway, so that's a kid and I said, work, you know, what does it mean? That was a big plus. So I had, I seen relation software before, and actually we did a little advising for them then Alliance. And I thought, this is perfect. This is what I need. It's missing some of the bells and whistles. I would love to have that. I continue to be a doctor and I didn't have the same big company needs cause I have a few lines.
So I think duration and then the schedule we had scheduling and I wanted patients to be able to schedule themselves. And at the time only, she didn't have that. So I went to intake sheet. Which is not integrated with the other systems, but is a very easy system to use. And I still use that to this day, even that's disconnected from I've linked it to hint, and I've learned more about how to drive people directly, someone that's in sign up using too.
And then I just recently started using scripts, which I really loved. So I'm a late comer just produce, but but it's been great. Tried to get us, I use that. We're probably going to switch over to video conferencing and students as well. Right now I'm using doxy meat, which I really liked.
But eventually, this, the cost of all of this addict. So if I've got another video platform I can use, it's integrated that. And I think that's pretty much it.
with you having the tech that allows you to have your practice the way you want it to be, that allows your patients to get the care that they need. And now you have a practice that allows you balance what does the balance in your practice allow you the time to do now?
From my days, working at the community clinic, I got trained to do forensic medical exams to asylum seekers. So I can gain that same skosh 2004, I don't know how many of them I've done over the years, but probably I probably do a couple of year on average. And those are really, that's a volunteer service for this network that helps connect with them.
The supervisors she can do that medical or psychological. I've always really loved doing it, even though it's often very sad and very disappointing to think about how terrible we are at each other sometimes. But at the same time, you are really helping someone it's a short period of time and you have to devote to it.
And and then the forensic part of the supervision. So over the years, I've got more and more into that, that the notion of learning about how the stars feel and how do you confirm or not that particular injury described by someone who has been unfortunate? Would it look like this or not?
Does it fit this, the score to fail? And to me say more likely than not this scar would be what happened if something like this happened to them. And sometimes they've been very, minimal lines. depths very, really think about a second. How do these things feel? I almost never write my report by the way.
I absorb and think about it because the forensic part of it, you really have to think about how do things feel and what would you likely expect? Because oftentimes it's years ago at the time there, I knew the silent process. The injuries are quite well, you know, here's the several weeks, so that's really good.
The end of life that I do that under the death with dignity law in Washington. I got involved because of the patient of mine years ago. He asked me to help. And I learned through that case about an organization in Washington called the draft Washington, which is one of the premier and non-governmental groups non-profits in the country supporting people who wanted to attend to him.
I wasn't doing segment. It's now called medications to aid in dying. So I started doing that several years ago. And initially actually, as I was building my practice and mine was a little bit tight, I had to charge for them. I would give it a. Do it as a donation with people holding independent news.
That's the most part. I was charging people position. When I got to the point where my practice was doing a pay, I stopped charging for it and was just really wanting to um, I do a lot of those cases cause there's a very big shortage of doctors. It has to be doctors who will do this and half of the healthcare systems in Washington state around that tactic institution.
So they can't. So it's a huge needed mistake. Those were really weren't intermittent, but the medication abortion work then I got involved in actually has become a daily part of the night. So every day I worked with several different organizations and I also have patients come to that place in their practice.
I just worked it into my schedule. Now we have a pharmacy that can ship for us. So I have to get all the orders in by noon. Otherwise they can't get them out that day. I have new orders that come in the new places that come in later in the day, I just didn't want to wait 20 minutes to do them.
It's very organized. We have a great set of teams who handle a lot of intake and we with you and all that. So by the time I am addressing the cases, except for my own, which I research to finish. There's not it's not a heavy list, but it's interesting. It's very special. It's just first trimester abortions, but there's a ton to learn and there's a ton of great people involved and it's all working.
Like I've never met any of these people that I work with to do this. And we used to be a ton of meetings and planning all this sort of stuff. And now it's what I'm really doing now. There's always something new I'm post-abortion is under attack in these countries. There's plenty to do, but we've also brought on a lot more people into this community.
So either water and having to deal with that at the war. There's lots of other people in walk. So those three things are hugely satisfying to me and the medication abortion work I do get paid for, but they're very inexpensive treatments need most, I I don't charge $150 and half of that medication.
So it's not like it's a big, expensive thing and it's, a lot of money, but it does bring in some revenue to my practice, donate a certain amount of cases as a meeting. So nobody gets turned away, which is what I do in my practice too. So if my patients fall on hard times, it just, they can pay whatever they can until they feel that they care.
And I it's up to me to figure out financially then to make that better. So as the medication, abortion work Ru, and between my piece of evidence, I just looked at my revenue like, okay, then I don't need to go on the back of this back to that discussion because I have this now I remind myself what if this went away or what is the Cyrus?
I saw the contact. It's a satisfied is just looking at to small numbers. That's what's CSR attorney, what does that mean? What did that program do? I gotta be ready. That's what does that chunk of revenue that it went away? What would I do? So that's a really important thing. So it's great to make time to volunteer work and also the staff, as long as you're thinking ahead.
Yeah. That's why it's, but what if this chunk of revenue fell away? And I put him through that and not just no, I don't want that back of bags. I want to know that I'm comfortable in that. So something happened. That's still.
when you talk about being prepared, do you have like a I'm set for paying my daily expenses and paying the clinic overhead for six months?
Or how do you set it up so that you feel financially comfortable, so to speak, if something were to drop off your plate, that was no longer bringing revenue in?
Yeah, I think in general that the business world's recommendations have six months of operating expenses. So I definitely have that now. It's so much easier now that I have someone else sharing the space with me, because my cost just dropped that. I mean, I was carrying a very expensive lease up until now.
So having that cut in half now I have a reasonable bent, but up until now, it's hard to save money because I was pouring a lot, need to, at least that was just way more than I should have ever taken up again. I had a lot of stuff to pay back and things to do more with as well. So it's really only this past year that I've been able to start catching that button on that.
So I would say now I have that money in the bank. Um, It's also an matter of predicting what clinicians things like, what are something terrible happened to me? I got hit by a bus and there's incapacitated in death. My lease becomes invalid or now this other doctor can take it over if she wants to So I realized oh, I didn't there's things, I assume things I don't have to feel responsible for it.
If you die or you're incapacitated to be of use for the enough. Right. So So that takes care of that bar that, my assistant would have to go find another job, but I've, made it from that to pay really well. So it's up to her to save for her future and have a boss of herself.
That's not my responsibility and that's what the arm I haven't promised her severance or anything something happened. So I didn't, again, expectations, I haven't set up a lot of expectations with people that I can't. So it was a big learnings and she likes it is don't promise a lot of stuff that you might have trouble.
So the six months in the savings, super important, making sure you're constantly trying to keep your expenses to a minimum. And then thinking, I always tell people think of the absolute worst case scenario. What is the literally worst thing that can happen in home. And then get real about it.
And they're like it's not so bad. I mean, The biggest issue would be someone, closing down the business if I couldn't do it herself. And if you have six months in the bank and everything goes haywire, then we've got some savings. But I think that the bigger picture is you discipline yourself early on as early as you can.
the time to not get too excited and practice steps to make money and start spending on money. That's the time that really print down and it's going say, you're doing well now. Now let me take that money and put it into a good investment in my future. And essentially and I've not been great about that in my lifetime, but that learning that lesson late, but it feels really good to be back.
If you are talking to somebody who doesn't necessarily have a lot of patients or they're opening out of residency in a new location and they're not known, so they work their first couple of months with five or less patients, what do you suggest to people in terms of when to take a salary?
So I think the easiest thing to do starting out with zero is tap some other job that you can do. And don't worry about not being sitting at the phone, eight hours a day, five days a week, writing for the patients there, we've locked with our modern technology. There's so many ways to be available to your patients without having to be just sitting there.
So we could actually be doing other jobs. You could be doing shift work, you could be doing all kinds of different stuff to bring in some revenue on, build your practice. Even to the point of saying my practice is just beginning, I'm going to be open three days a week and then I'll be available for messaging.
Other times I'll be available two days a week in clinic and the rest of the time Thursday. So having some other source of empowerment as a doctor, you're so in demand, and there's so many jobs out there's jobs we can do at the front line.
We can disabled during her career. So she now does your organization review for one of these companies that does hospital utilization review, it's all remote and always has been. And so you can be prong reviewing charts and doing that kind of stuff. So you have to be creative about the other work they can do.
I would highly recommend that because then we can relax. You've got to that. And you moved up. It would just not put the money down to, and if he can find a small space that presents or do mobile, only as I know some people have done that's ideal. And then in terms of taking a salary what I've done for quite a while is I just.
I in my bookkeeping, I just say on understanding personal expenses and understanding person expenses, I didn't really bother to make myself in today. And then just make sure you pay the social security and Medicare and all that, which at some point you have to anyway, it makes you do that. I think that's how I handled it.
I didn't really need to make myself as employees. The reason I got health insurance through the exchange that was actually cheaper than putting myself on my employer until you plan because of that age. There's lots of different things you can do like that. If you have a spouse, you can be on their health insurance plan.
That makes sense financially. Yeah. Another reason for not modeling for yourself. And so that's been hard.
And one thing I just want to put here, especially for people who might be new to the podcast or who are exploring DPC for the first time, is if you are going to take a job to support your DPC, definitely pay attention to the non-compete clauses.
And if they're enforceable in your state, because multiple physicians have talked about, they have to practice so many miles away from their previous practice, or in some states like California, it's not enforceable. So definitely an important thing to, to figure out if you're planning, DPC for your
future.
The other thing too is don't forget some residencies and that the schools need preceptors. And it's paid, then you could use a precepting and those are fairly short shifts. So usually half a day or something. Really some work to do. I never did that myself, but I know a lot of people who've done.
Awesome. So going back to the fact that you have been there, done that seen at all, and you're still thriving as a solo practitioner. I want to ask,
When you think about the movement, what could you say to other people in terms of when they're talking to people who don't know about direct primary care yet, or they don't have the tools to understand really how to do it.
What is the way that you would, challenge people to potentially talk to those fellow physicians and say, Hey, this is what to think about.
If you are really, looking for another way to do care
I don't think about that because I talked to so many people since the arm.
Yeah. The beginning of the Alliance about this particular thing
What I say to people is don't think of DPC as this. Shangri-La you're going to step into a new world. It's going to be perfect and everything's wonderful and goodbye whatever it's work. What we do is work.
We take care of people. Healthcare is, it's just a difficult endeavor because it's thinking about all the stories you just hear from people, incredible stories, they're bad and other, and you carry that with you. No matter what we do, I'm not talking about the earn healthy. I'm saying we are the confidant of so many people that did that.
And the other times of day. And the thing that I think is so great about DPC is that semen engagement is it's unbelievably rich in a way that I don't know because I'm not in tune for service. And I only did three years in fee for service in a community clinic setting. But for, I hear from my colleagues, it just sounds unbelievable how not that is and how difficult it is when they do establish and maintain.
Pretty deeper to the patient is I think that has been a miracle. Whereas in DPC, it's destitute, it's routine that your patients didn't even know what's going on with them. Then you're connected with them that you are involved to the level, need to be involved and giving time and that we grow and we recognize your ground sounding experience as well.
Talking about the dialectical nature of the relationship. But like anything you get out of there, what you put in and giving up, working for somebody else and working for yourself is a transition. I haven't done any other way. I'm not great at the other people. And I think our doctors and you take on managing all this stuff, but I think the key is if you go into it intentionally thinking, what is it that I truly believe that through the river set those expectations of yourself?
We keep those to other people. When it doesn't work, make adjustments, they want to read to change their mind at any time in their life and thoroughly run that. So if you realize that with DPC, you create your reality, you create the future. It makes it so much easier to deal with all the specifications of the healthcare system that you will have to deal with prior authorizations and referrals bad things happening, all that kind of stuff.
Um, And just stuff didn't engage with the rest of the system. It's just that you are not being freed by that systems are gonna need to be that. So those would be the main things I would say to people, issues are more. And if you're worried it put in the work and take on the responsibility, but it's not the heavy burden, it feels light because you are getting so much satisfaction.
isn't.
Beautiful. Thank you so much, Dr. Bliss for joining us today. It was such a pleasure. My
pleasure. I really enjoyed it and kudos to you for doing this, your whole approach. And what we're doing for the community is just tremendous. I believe.
*Transcript generated by AI so please forgive errors.