Direct Primary Care: Dr. Minda Gold

This is Dr. Minda Gold. Dr. Minda Gold is originally from New Jersey and she and I had intersecting and parallel for many years family medicine paths, but she most recently is doing some very fascinating work in the area of direct primary care. So I thought we would bring her onto Radio Maine and have a conversation today. Thanks for joining us. Thank you. I have to say that I have a whole kind of a shortish list of people really impacted my family medicine career and I have to put my dad at the top. But you're pretty close to the top. I mean, you were one of my early mentors. I worked with you in your office in Damariscotta. I worked with you as a medical student, as a resident, so I'm pretty much in this field in part because of you. Well, thank you. And I will have to also say that your dad was an amazing mentor to me and I feel like I've been part of the Belisle family since I started medicine because of everyone in your family. Well, there's enough of us kids that he probably wouldn't notice if you showed up one day and we're like, oh, it's just me. I'm just one of them. So I'm interested in why, I mean, starting out in New Jersey and coming to Maine and then basically we caught you. Here you are and you're in Maine all these decades later. What was the initial attraction to Maine and what has kept you here? I think Maine has always been my final destination. I lived in suburbia in New Jersey and mostly spent any free time in the woods building tree forts, getting out into the mountains if I could. Although many people have no idea that there's forest and mountains near New Jersey. And when I went to medical school at a tertiary care trauma center in Newark, New Jersey, I knew I wanted to do family medicine. They didn't even have a department. And one comment I got from an attending was, you're too smart to be a family doctor. And I didn't know really how to take that, but I knew I wanted to family medicine, I had an amazing GP growing up and that was the path I wanted. So I interviewed throughout New Jersey, Pennsylvania, new England for residency, and I fell in love with the Portland program. I connected with John Randall, the director at that time. We had both been in an outdoor leadership program at different times and that really connected us. The residents were wearing Birkenstocks and I think I was the only one in New Jersey at the time that wore Burkes and they had the attitude of how important family medicine was. It was really one of the first times that I just felt all of that energy around the importance of family medicine. So Portland was the place and after I did my residency, it was clear that I wanted to stay in Maine. It was just absolutely gorgeous. Even after a really tough shift on trauma surgery, you'd come out and see Mount Washington. And my husband also, he went through the whole process with me from acceptance to medical school through residency, and he also loved the woods and wilderness and Maine was perfect for both of us. It's interesting to hear you talking about kind of the history of family medicine is really what you're saying because family medicine is not a very old specialty per se. I mean it's really only about a half a century old, although it's been around forever. Caring for families and communities has always been important. But I find it fascinating that when we went to this specialty kind of care, all of a sudden if you were a surgeon, you kind of rated you were very important, you were the real doctor and everybody else just kind of fell into a different bucket. And it's like, oh, well you couldn't be a surgeon. You're not smart enough. So you get to be a family doctor. Family doctors have to know so much. We have to be emotionally intelligent. We have to have data, we have to be up on the trends. We have to be able to talk to people. And I'm not saying that other specialties don't have those things as well, but the breadth of knowledge and the ability to hold all of that and be able to connect with people is not as easy as people might think. You're a hundred percent right. And I think also even extending to the medical mil now, which a lot of primary care docs or even family docs, many are in situations where they are the person who does the referral to a specialist. And I am fortunate enough to say that I trained at a time where we learned to do things, we did our procedures and we helped and we did deliveries and prenatal care and surgical excisions of things. And that's really the wealth and expansiveness of family medicine. I've had many people through the years, especially students say, how do you learn all that stuff? How do you keep all that in mind? And I think some specialists feel the same way. Well, they can't really be too good at anything. They're probably fair at a lot of things. And you do incorporate things because the human body works together and it's important to be able to incorporate all these things and the medications and the treatments we offer. I agree with everything you said. And also I think the value of truly being a family doctor, I mean all the things that have come through, I mean we were considered gatekeepers. I think we're still kind of considered gatekeepers to the concern about the referral. We're just between the patient and the dermatologist, but that's not really where the value lies. The value lies in actually knowing the families and seeing people longitudinally. So I will see people on the street now and they will say, see this 20-year-old you delivered this child. And I'm like, that is a whole other generation. And I think to be able to say, I know your father, I know your mother, I know your grandparents, I know your children. The context in that just gives us such valuable information As physicians and healthcare practitioners generally, I see notes now come from a consultant and it speaks only of the person they're seeing a 15-year-old with struggling with anorexia and it talks about her, and this was one of the major motivating factors to go into medicine is in training. I would see somebody and I would say, oh, this young child is coming in with an asthma exacerbation. Dad just went out to have a cigarette smoking in the house. Wow, that's related. And I remember saying to one of the surgical residents, I think we should talk to the dad about smoking around this child. They have asthma. They actually had a pneumothorax, they needed a chest tube. And the surgeon said, we are surgeons. We don't talk about smoking. And I was just like, we do talk about smoking. And similarly with the child with anorexia, knowing the mother, knowing the father, knowing the siblings and what struggles they might be having, all of that helps you take care of the person that's in front of your eyes. And I really think we're doing a disservice when we talk to people in isolation. We don't know about their family. I think I've been casting aspersions unwittingly on surgeons at this point. Oh yeah, why did I say that to you? I want to be really careful because I know lots of tremendous surgeons who are very good about understanding context. I mean, my father, before he passed away, he had a neurosurgeon who was the most personable, the most family oriented, communicative individual. And I have lots of friends and family members who really care about people in their context. But hopefully if you're going to have neurosurgery, you're probably not going to have that many incidents of neurosurgery hopefully could happen. Whereas if you truly have access to a primary care practitioner, then hopefully that would be a longitudinal relationship. But it speaks to something that is, I think why you shifted the way you do medical care. And that is that that was the way it was. And it has increasingly moved away from that in most medical practices to a more transactional, I'm going to see you three times and then I'm never going to see you again. But you've decided that you wanted to do direct primary care. You wanted to go back to what's more like the original model of family medicine. So talk to me about that. It's very interesting because yes, that's what I do and I've never really looked at it as that's the way we used to do it, but it is so direct. Primary care is returning to the model of the physician working directly with their patient. There aren't middlemen, there's no insurance company saying you can't address that at this visit. You'll have to put in another code. There's no one knocking on your door saying you've exceeded your 12 minutes, your 15 minutes, you're 20 minutes with this patient. You need to move on. Your room with the patient is an open palette for that patient. And if they come in and their plan was to talk about a wart on their foot, but oh by the way, while they're there, they want to talk to you about something they're really emotionally struggling with or an issue with their child. It is possible and it's actually welcome to address the needs that that person comes in with that day. And we really look at it as medical care. We talk about medical care and who's your PCP and who's your insurance company. And we truly look at this as care. And a lot of the systems that have developed out there are so involved with metrics and numbers and RVs and management and very top heavy with management looking at the financial issues, the bottom line that the doctor who's really the one who's giving all the care is just restrained in so many ways. And in this model you lose all those constraints. I mean, some of the things I get to do, I get to do a home visit on a patient if it's easier for me to go see them than it is for them to come in. And I can't do them all the time. And they're generally for patients who are in maybe in hospice or palliative care, I get to schedule an hour long appointment with somebody or two hours if needed. We're sort of one of the original founders of telehealth when covid hit and all the hospitals and doctor's offices were scrambling to put in systems for telehealth. Direct primary care had been doing this. You can access us by phone, by email, by text, by coming in person. Those have always been options for direct primary care, which we call DPC. So it's really built around what works for the patient. One example that I love to give is you feel like you have a urinary tract infection. You try to call the doctor's office to get in and you're put on some phone tree and I don't know, I'm just going to say it takes you 15 minutes to get a human on the line and then you try to get an appointment that day, you're likely going to be told to go to urgent care or somewhere else. If you get an appointment and you get there, then how long are you waiting in the waiting room? And let's say you're waiting in the waiting room for 30 minutes and patients know that can be much longer. You get into the office, you're seen for seven minutes, you leave with a prescription, you go to the pharmacy and now you wait an hour for your prescription before you know it, this simple UTI has taken four hours and it's really dug into your workday and you feel miserable. And with direct primary care we can see you that day. We can talk to you on the phone depending on where you are. If you can't come in, we can advise you when you come in. Many DPC docs in Maine and even throughout the country have common medicines in the office. So you can leave with a prescription for .42 cents and go back to work. And patients leave happy, they leave fulfilled that their questions have been answered. I just remember the stress in traditional fee for service medicine where you'd call somebody, it would be eight o'clock at night and they'd say, I've been waiting all day for your call. And now the pharmacy's closed and they were all fired up because they had all of these concerns and they didn't think they were going to be heard or taken care of. And legitimately it's like going through Fort Knox to reach you to speak to you. And I have patients now who will say, wait, you're answering your own phone. This is great. Or I just have a quick question for you. And you say, great, what is it? Or they call your medical assistant and it's one person they need to talk to patients even when they're really sick, are happy to be able to get the care that they need. And so it is the complete opposite of physicians burning out in medicine where they feel like their inbox is always full. There's always another task they can do. They're never appreciated. They're overworked. Patients are always complaining, I can't get back into see you. I understand why so much burnout, and this is not everything is wonderful in direct primary care, but so many of those issues are built into what's the root? The root is I want to have a relationship with my doctor, I want to have a relationship with my patient. Let's do it. It's kind of interesting I actually was in what was essentially a direct primary care model and I was leaving that model as you had transitioned into that model. And it was relatively early on in the process. And I would talk to patients and they would say, well, what do you mean you're not affiliated with an enormous system and you're giving me your cell phone? That for them was so unusual. And I would talk to physicians and they would say, well, aren't they calling you at all hours of the day and night? And at least for me the answer was no, because they know that they can reach me. It was very rare that I would actually get an inappropriate call at a random time because people felt comfortable that there was somebody who was going to be paying attention. And there was something really special about being able to do that work and have that practice and something really gratifying. And also I knew that if I needed to pay my own light bill, then I was paying very close attention to my finances. So it really wasn't a question of I wasn't paying attention to metrics. I was absolutely paying attention to metrics and quality and patient satisfaction, but it was me and that was my choice and it was my way of practicing and it was a great relationship with patients. And you were able to witness the patient's surprise when they heard your response to things. Many people still don't understand direct primary care. You really try to clearly explain it a lot think it's concierge care, which in the DPC world we kind of call it concierge for blue collar, which is okay. But basically concierge is a membership based model and those practices still bill your insurance company when you come in. So it's kind of a retainer to have a doctor. But other than that, it's pretty similar to your standard offices. By paying that membership to them, they can spend more time with you because they need to see less patients with direct primary care, we do not bill your insurance company for a visit. So like you said, your electric bill or your cell phone bill, there's a membership. You can call me 12 times, you can call me three times. You can come in once a year. That membership per month covers those visits. So it's great for people who have a very high deductible plan. It's great for people. I mean when I started, I started seeing local artists and carpenters and fishermen who hadn't been to the doctor for 25 years, they couldn't afford to go. And they're like, well, I can figure out how to do this for $75 a month. And I also have patients that have what we call in medicine, excellent insurance plans. And that's usually based on a low deductible. That's nothing to do with the kind of care you're getting, but many people say, well, I have a great insurance plan. Why would I also want to have a DPC doc? And my response is usually tell me what you're unhappy with in your current situation. And when they explain to me, I can never see my doctor, I always see someone else, I can't get on the phone. There's no communication. They basically write the script for me and I say, well, with direct primary care, we've gotten rid of all those barriers. So it's just so nice to have, like you say, have that relationship where you know the person. And I would say from colleagues, yes, one of the huge concerns is they have your cell phone. You're on call twenty four seven. I don't know why it took me 35 years in medicine to realize that patients often call after five o'clock when the phones turn over, why do they call on call for the back pain they've had for two months? Well, because at 5 0 2 they get to talk to the doctor on call. And from 8:00 AM to five, they get to talk to the receptionist. Who's going to tell the medical assistant, who's going to tell the nurse who's going to give it to the doctor, who's maybe going to come back through that ladder? And as you said, patients know that they can reach me during the day and they are so respectful of my time. I mean a lot of times if they message me on the weekend on our communication portal, I am so sorry to contact you on a Saturday. It's just that I was thinking about my whatever. Please do not answer this until next week. They don't want me to burn out. They recognize that it's a crisis in the country that doctors are burning out and are overworked and underappreciated. So yes, you're on 24 7, but again, I rarely get a call off hours. And the other thing that's wonderful is the direct primary care network throughout New England and Maine in particular, we have a lot of docs opening up. We cover for each other and it's not a I covered for you seven days, so you cover for me seven days. It's literally a text. Hey, it's a great weekend. I want to go skiing. Can you cover for me? Sure. Put my number on your machine. So there's so much comradery and support from the other DPC docs. Something I never experienced in the traditional model, And again, this actually was the way medicine was practiced, right? I mean some things have changed for sure, but in the original model, when my dad moved to Yarmouth, Maine and he was part of a small practice, patients knew him, they knew him, they knew that he had a large family, he would be on call, but they respected his time. They knew that. I remember he took my sisters and I into the office and he would, back in the day, he would plate his own strep swabs. So he'd go in to read whether patients actually had a strep strep throat infection based on the auger plate in his own little laboratory. But patients knew that he had a life and it wasn't as transactional. And I don't think that what you and I are saying is that the current traditional model is not acceptable for anyone. Some people do fine in it. And also let's have an additional choice for people who really do value the person who's on the other side of the phone. It's not just like, I'm going to take whatever person is available right now. I want Minda, I want Dr. Gold to be caring for me. And if that is important to people, then that is just going to be a better model for them than what currently exists. I agree. There needs to be a choice for individuals and it is not the model for everyone. However, I think speaking to colleagues of mine who are in an employed fee for service model and especially as larger groups buy up different practices and make things more uniform, we're going to have the same policies at say Maine Medical Center as we are at Lincoln Health, a small community hospital. They are different environments. And up to this point, the smaller hospitals have been able to have their own bylaws and rules and regulations and they understand what's different about living in a small town in a small community hospital. I hear from my colleagues that they're not many are not happy and I go as far as to say most are not happy and it's really sad. I love medicine. And they went into medicine for the same reason. They love it and they are dedicated to be great docs and have time with their patients. And I sit at a med staff meeting and it's all about numbers because that's what can be measured. How many people have received a pneumonia shot and when they came in today to talk about their anxiety, it's not as important to ask them about their pneumonia shot. They want to know you're listening to them. And when you say, and have you had your pneumonia shot? To me it feels like, do you know why I'm here? Are you even listening to me? What is it that we want in any other area? We would never get away with this. If you went to buy a car and the car salesman tried to sell you a truck and you wanted a mini Cooper, you'd leave them. You'd say, listen to what I'm saying to you. So yeah, really getting off topic, but it is definitely an option. I think we need more. So one of the things that I find interesting is that you began your career during the AIDS epidemic. And for me, I was not in medicine yet. I think I was still in high school, but that was a big, big deal and now fast forward a few years, About 30\! Yeah, we think about AIDS really differently. We have different treatments. Essentially it has become a chronic disease. It's now very treatable and livable and actually cancer is heading in that direction as well where it's not necessarily an immediate end of life situation. There are a lot of things that are now available. And so here we have, those are just two examples of technology that has enabled us to do healthcare better. So why the pushback? Sometimes I wonder about innovative models of care or not even particularly innovative, something that used to happen and now we're bringing it back in a different way. Why is it that people have such a hard time with something like direct primary care or maybe virtual care telemedicine, when we get pushback from people like, no, no, no, we have to do it this other way. This is the only way. If we thought that way, we never would've come up with a different way of dealing with AIDS, right? So do you have any thoughts for me as to why it is so difficult to shift people's mindsets around the way that we offer care if we've been able to actually address medical issues differently, even the course of our professional lifespans? I think it's always important to look back as we look forward, what works, what doesn't work. And unfortunately too many businesses and models are run based on the bottom line on the financials. And yes, that's reasonable because you need to be able to survive and bring home a paycheck to support your family and the business needs to be able to cover their expenses and such. In medicine, it's so much more than the financials. And if you can make the financials work and provide a richer, more robust model that's addressing the complaints and the needs that people are expressing, then why not do that? You may go to the doctor and then get an email that says, please rate your appointment. And it goes everything from the person that the receptionist to the person who took you to the room to maybe your interaction with your provider. And they're doing that because they're like, okay, what can we do? We need better scores here. I think we're just putting so much energy in the wrong place. A lot of people in medicine and in DPC say the medical system's broken, all of this technology, all of the advances we've made in treatment, many of those are really good. Like you say, treatment for AIDS is a chronic disease versus never leaving the hospital when you're born with AIDS and getting schooled in the hospital until you die with the children that were there. But we can't lose sight of who's our audience. We're taking care of people. We have AI now and we have electronic scribes. So you're in the room and in some offices where you can look in the eyes of the person, you're talking with the patient and you don't have to take notes because there's someone listening and I don't want to put that down. I think that's important for many people. It answers the question of yeah, have a face-to-face encounter with me, but it's mechanizing the relationship still it's having someone else write the note. Why? Because there are certain things that need to be documented. If you don't document 'em, you get dinged. And the focus should be what documentation is necessary. So this patient gets excellent care. They're not equivalent. It's really sad, but they're not equivalent. I do have to agree. I mean I think when we, having worked for larger health systems before and looking at these metrics and the things that they wanted us to pursue, a lot of it was because of what we called the payer relationships and it was the contracts with insurance companies or with Medicare for example. And I think often what would happen is these large organizations, we're trying to find a way to offer more efficient care. Let's look at it into the most positive possible way. We want somebody's hemoglobin A1C, which is a long-term marker of how your diabetes is doing. We want it below a certain level and we're going to measure practitioners based on that. So it kind of maybe starts in a great place that all of these things we're measuring are potentially going to be helpful. But I think by the time it ends up in front of the patient and the practitioner, it has gotten so distorted that the intention is not really the same. And it really does end up, as you say, becoming a barrier because if you spend all your time clicking the boxes to make sure that you're getting your numbers to look good, then what you're not doing is really understanding, oh, this person waited for two years to come in and see you, and they're probably not going to want to talk about preventive screening. They probably want to have this big mold that's been growing on the back of their hand and looks pretty ugly now because it's taken two years to get in. That's probably what they want to address and probably you should be addressing it anyway. I think the other thing with direct primary care that we focus on is transparency. And this is really horrific in the medical system, even though there are price lines that you can call and systems federally are supposed to list online how much things cost. As a physician, I struggle to get the price of something and anybody out there who has tried to get the price of something, I challenge them to show me the price they were given and then their bill and have them match. So in direct primary care we are transparent. You know exactly what you're spending a month and if you come in and you need something done, we can say to you, oh, that EKG, there's no extra charge. That's strep screen. There's no extra charge. You want a flu shot? Okay, it's $12 or it's included in your membership. You need this medication. And as I said, we do dispense common medications. We can tell you right then and there, it's $6. You need a knee brace, I can order that for you. It'll be in tomorrow. It'll be 34 87. So all of these things that take up so much time and are such a mystery in medicine are laid out for you, which is what we expect when we're having any other, when we're purchasing anything else. Back to the car model, how much are the mats, the floor mats? And so that is something that I never knew anything about when I worked for a larger system or when I worked for a fee for service model. And now I think we all should know if I order a vitamin D test on someone, it's easy for me to print a lab slip. If they say to me, how much is that? I mean, I had no idea. I had it done several years ago, it was $144. It's more than that now. And I can say to someone in my office, if you do this, if you have this test and you pay by cash or use your HSA, you don't run it through your insurance. It's going to be 1287 if you use your insurance because of everything the lab company needs to do in order to get the insurance to reimburse them, it'll be 112 people. See the difference. I difference. I can say to somebody, you need an MRI, I've researched this. If you are willing to drive 45 minutes, you can have that MRI for $680. If you have it at the local hospital, it's going to be $1,300 plus you're going to get a bill from the radiologist. I don't know how much that's going to be. So we pride ourselves in finding excellent care, excellent options, standalone facilities. So if you don't have to walk into a hospital to have a test, you're going to save so much money and being able to assist the patient in navigating that system, which I never had the time to do or the knowledge to do in traditional fee for service medicine. It's so interesting because when you talk about helping the patient navigate the system, I think that ultimately in this day and age where people have a lot of access to information, so they're probably coming in with a lot more knowledge of not only medicine generally or their bodies, but themselves specifically. And sometimes what they really want from you is like, this is what I've been thinking, this is what I think. And what do you think? You've been in medicine a long time, give me your perspective on this as opposed to, I have no idea what this is. My throat hurts, but I really don't know what it is. Most people have some sense of what might be going on. And the simpler things, and I do love that you're able to, for example, you can go to the website and you can tell the patient, oh, well just go and click these boxes. This is what you need to order. It's going to cost you $214 to have these tests. And guess what? You can have them drawn at Quest, which is where everybody else has theirs drawn. If they go through a traditional healthcare system and that you're still offering really good care, but you're actually involving them more in their own care than if you were just to make decisions for them and just hand them things and say, here, do this, here, do this here, do this. And there's something really important about that, giving people back the access to the information and resources they need to care for their own bodies. And in that, keeping them happy. They're not resentful. They don't get the unexpected bill like you asked me to get these labs done and my bill's $634 and I have insurance. How come it's $634? Well, you didn't hit your deductible yet. And patients are very unhappy and they don't understand the system. And even when you try to get help, it's very difficult to understand the system. If anybody's had the experience of calling an insurance company to ask, why isn't my inhaler covered? If you get off the phone within 45 minutes, that's a great day. So we try to really minimize those interactions and have the discussion with a patient to say, this is why we're suggesting it this way. You are absolutely welcome to go to the pharmacy, have your insurance pay for it, or bill this through your insurance. You're absolutely welcome. We want you to know, like you said, the options of care. We want you to know the options of covering this service. And patients do come in, they come in with printouts and Harvard Health Letter and Mayo Clinic and sometimes from sources that I look at and say, well, this is as we were trained, not evidence-based, something that I disagree with. But it gives us the opportunity to also disagree and fo