Episode 61 of the Hope4Med podcast features Dr. Kristen Nebel, a board-certified family medicine and geriatric physician who began a home-based concierge practice in the midst of the COVID pandemic. Her goal is to love what she does and meet the needs of her patients and their caregivers, so when she was feeling disillusioned and unfulfilled by the system she was working in, she knew it was time for change. Dr. Nebel shares her experience with burnout and discusses the taboo that still exists for mental health issues, such as depression and burnout. We talk about how shifting practice models has helped rekindle a passion for medicine and return to doing what she loves.

Connect with our guest:
Website: https://www.peaceofmindaging.com/

Transcript:

[00:00:00] Dr. JB: Welcome to Hope4Med.

[00:00:03] Hi everyone, welcome back to the Hope4Med podcast. I am your host, Dr. JB, and today’s featured guest is Dr. Kristen Nebel. Dr. Nebel is a board-certified family medicine and geriatric physician who began a home-based concierge practice, mid pandemic. Her goal is to love what she does and meet the needs of her patients and their caregivers. Welcome to the show, Dr. Nebel.

[00:00:34] Dr. Nebel: Thank you for having me.

[00:00:37] Dr. JB: So Dr. Nebel, let us start from the beginning. Please share with my audience your origin story.

[00:00:43] Dr. Nebel: Oh, I like that term, I feel like a superhero in the house.

[00:00:50] Dr. JB: You are a superhero!

[00:00:52] Dr. Nebel: I have too many boys in the house. Great question, or great, yeah, thank you for allowing me to introduce myself. So I am probably, I guess I’m mid career maybe, I don’t really know what that is but that’s where I think I’d pinpoint myself. And I had been working through residency and fellowship in geriatrics and then about 15 years into it, just started feeling really heavy. You know, it got to the point where I wasn’t in love with what I was doing anymore. And I, oh gracious, I noticed like making like little mistakes, like taking care of patients. I noticed not being able to recall details for patient care, like I used to be able to mentally like tick through someone’s med list without looking at their chart. I just knew them so well. And. Able to do that anymore. I’m going to work was feeling like a chore. And I remember one day just kind of, like being afraid to leave, like to step into the garage, to get into my car, to go to work and I knew that that was not a great place to be at. I was in a in a medical director management role for practice in a large system at this point in time. And I really, I enjoyed that work. But I think I, was frustrated with, was just kind of layers of administration and. Limitations to the ability to kind of adapt and, and really meet the needs of individuals. And also, kind of probably like everyone, just the sense of not getting Just not getting that fulfillment out of, out of seeing patients kind of feeling rushed through those.

[00:02:30] One night I think it probably was in March of 16 or something. I remember just laying in bed, like in the fetal position and just kind of shaking and crying and clearly having an anxiety attack and just knowing that something had to change. At the time I was a mom of two boys and now I’m a mom of five boys. But you know, between having a home and a family, a husband, and a full-time career there was just no time for me, no time for kind of really taking care of myself. So I took 12 weeks off for FMLA and I’m grateful that I was able to get that time off approved. I know around the same time my own primary care provider was going through, I don’t recall exactly what type was going through some type of blood cancer, not leukemia or anything, but was like she wasn’t getting FMLA except for a couple hours to go get her treatments once a week. And that just–

[00:03:30] Dr. JB: Oh my goodness.

[00:03:34] Dr. Nebel: No, exactly. So I am grateful to the God above for giving me time, a full 12 weeks, that I was allowed to be off. And it may be telling, because people treat mental health things with, with they just don’t want to kind of go there, or refuse your FMLA for those types of things. But I had 12 wonderful weeks off and it was really a chance to kind of sit back.

[00:03:57] And I really struggled, I was really questioning whether or not I wanted to stay in medicine at all. And I’m thinking, I don’t know how to do anything else. I sit in my early, late forties, early or late thirties, early forties at that time. And you’re kind of overqualified by training and position for a lot of things. And I was feeling I had no idea what else I would have done. And so the more I kind of sat back and journaled and just really listen to some other inspiring physicians who had been through burnout. And the more, I, I just kind of listen to myself and kind of reconnected with myself, I realized that same passion and drive for becoming a physician in the first place was still there. And that I really truly did love what I was doing and caring for patients, I just hated how I had to do it. And so at the end of 12 weeks, I went back in, you know, part of just re-introducing myself kind of back into the workplace after burnout really was I stepped down from that medical director role.

[00:05:04] The less the less I had to do with administration, I figured the better I would be. And so I cut that out. And that took out a lot of times from the schedule. As I had met with the interim medical director and coming back and after just kind of relearning about myself and who I am and, and really understanding and appreciating what my needs are as, as a person and as a wife and a mother and a physician, I went to the interim director and sat with them and let them know, okay, these are my needs. And they weren’t anything that was really truly, I don’t even know how, like, it should not have been too much to ask, but in the body of that type of work and the expectations that come down and come through a system where everything for everyone has to be standardized. It just, there was no room for any type of variance and I didn’t expect there to be, but when I got the response a day or two later about my requests that said, that’s not how we do things here, I knew that it wasn’t a place that I could stay. But interestingly enough, like even, even though I heard that, I didn’t really act upon it or do anything about leaving for several more months. And a large part of that was just the indebtedness and the attachment, I guess probably unhealthy to some degree at that time.

[00:06:31] But just, I felt like I needed to be there for my patients. So I finally, it was a few months, well actually, probably maybe four or five months later before I actually started looking for another position. And I had to get to the point of putting my needs above my patients’ needs before I would really could allow myself to, to look for something. I’d been their physician for over 10 years. And there were a lot of really good relationships, but I just had to personally get to that point. Which is kind of interesting because burnout and not being available to my family for a good probably six months to a year before that, cause burnout doesn’t just start when you take your FMLA there’s time leading up to that.

[00:07:21] But even going through that wasn’t enough to really help me reprioritize things. So once I did that and had given my notice, I had accepted another position again in a different leadership type of capacity in the area. And yeah, I think I didn’t expect it to be very different, but at the same time, because my whole residency, fellowship, and, first, 12, 14 years of my career had been in the same system, I felt like I owed it to myself to at least make sure that it wasn’t like this, or to see if it was like this everywhere. And I quickly got my answer. And so, two years after being in that position, I submitted my notice and I stepped out.

[00:08:10] And so by this time, we’re in June. Well, I gave my notice, I think in April or May of 2020. So we’re literally, the pandemic starts in March and this is just a few months after, and so there was a variety of responses by colleagues and friends. And interestingly enough, when I gave my notice to then start the concierge in home medical practice, the idea for that practice which is really what I continue to use, but that idea for that practice came to me as I worked through those 12 months, or 12 weeks during FMLA to kind of formulate what my ideal practice looked like. And so here I am now I guess, about a year and a half into that concierge model. And as I said in my intro, you know, really what are my goals. And so it’s always to meet the needs of the patients kind of in the simplest way possible and just kind of meeting them right where they are at. So my practice is home-based and it’s largely is the geriatric population.

[00:09:23] And so if you step back to mid pandemic, it really is kind of brilliant because nobody was leaving their homes and the senior citizens who were in their homes at the time. The way that we did medical care for those at least for six months was mostly virtual. And if anybody during that time and even presently is doing or has done video visits with an elderly individual, they can appreciate the struggle. Um, So, I decided I didn’t need to be afraid of going out and about, we have PPE and we have protocols to put in place and there’s a real need for this population to still receive good care. And so that was kind of where, meeting their needs and then making sure that I’m still in love with what I’m doing.

[00:10:14] Mainly because as far as I can help it, like I never ever want to get back to that point where I had been previously, it’s not a great place to be. You’re not available for yourself, your family, or your patients. And I do truly believe that we– I don’t know, medicine is such a cool field and I really am in love with it. And there’s just such a wide variety of how you can practice. One of the things I love most about just my day to day practice is if an individual, a patient or even their family member has a need or a question, I just brainstorm, Hey, what could we do to meet that need or to make this happen? And if I don’t have supplies, then I get them to be able to do that. As long as it’s within my wheelhouse, I’m not gonna do anything that puts me or them at risk. But there’s so much more creativity that I’m able to do, and I really enjoy that part of it. So that’s sort of me in a nutshell, I guess, pretty much what the last, probably about, that’s about the last five years of where I’ve been.

[00:11:22] Dr. JB: Wow. And that’s been quite a ride those last five years. And so one of the things that you mentioned, you said that burnout did not start from right before you took the FMLA. When did you first start experiencing the earliest signs of burnout?

[00:11:37] Dr. Nebel: Yeah. That’s a great question. I would say as I’ve kind of looked and reflected back on that, it was probably about even two years before I was willing to recognize it. And it started as depression. I just was not enjoying the work that I was doing every day. I got to the end and what really hit me, and I’d heard someone else say this too– and I can’t recall who I had heard it from to kind of give them credit, so I’m sorry– but it was when work feels more like a chore then, you’re probably starting to have some of that, you know, blocked care. You’re starting kind of down that, down an unhealthy path. So for me, it was about two years and I became really cynical. I’m a little sar– I love sarcasm and so I’m just that by nature, but it was more than that, like it just became really, I think cynical is probably the right word. I just looked for, an ulterior motive to anything or everything that you know was coming my, I say coming down and that’s probably not a great term, but just every, oh, the additional quality measures that were being added and kind of every little nuance in the electronic record that was being added.

[00:13:00] Like it just, I really struggled to find anything in a day that I enjoyed doing. I could not wait for the end of the day to come. And then that I think that just slowly, yeah, just transitioned in and anxiety became a feature of it. I think just because I was kind of so miserable when I was at work that I kind of dreaded going, and so then that just created kind of the anxiety as well. Yeah, sure, I tried SSRIs and SNRI and whatever else, I never went to like benzos or anything. I just didn’t feel like that would be a great place for me to go to. But, and I always say, I think medications help you tolerate things a little bit better but they certainly don’t change the things for you. And they don’t um, yeah, I guess that’s probably about it. So yeah, I’d say it started as depression and then anxiety was added to it.

[00:14:01] And I think my husband who, he doesn’t notice a lot, he’s a great guy but he’s usually pretty reserved and like doesn’t make an awful lot of comments, but I do remember him just being like, I’m worried about you, this is not a good place. And then I actually, one of my mentors slash friends had also, you know, was noticing changes and just really encouraged me to do something. And so yeah, so that was kind of, I think that’s really what spurned me to kind of just take the time off and so I’m really grateful for that encouragement.

[00:14:39] I’m sure I saw, I think I saw a counselor or something during that time too. It all blurs together. Shortly, not shortly after that but a couple of years after that, we had we had an adoption as well of a sibling group into the family and so I feel like the last five years have all been like therapy for one thing or another, but that’s okay. Yeah.

[00:15:01] And I think, gosh, one of the, I think that I thought about this because it is still a taboo subject despite all the awareness that’s brought up about mental health, it’s still relatively taboo. And I think especially within a professional field, you know, medicine and it, I hadn’t really appreciated that. I’m generally just kind of an open book type of person and I just see my experiences as if I can help use those, to help the next person, like, that’s kind of what I’m here for in life. But I remember when I was leaving that first place after burnout and then going into the second place, the second health system for that role, that I got a call one day as I was doing my credentialing process for the new system. And that’s just kind of an onerous process, but I got a call for, I forget what it was, but the medical committee and they had asked me that, apparently like when you do the references, when someone writes you a reference for your next position– this is what I assume happened– so she called and she had said, this lady called for this just to kind of, yeah, she called and she said that one of my reviews, in the box that had asked, “can this individual perform her function and her duties as needed,” essentially that question that’s in all of them, he had checked the box that they should talk with me about it. Yeah.

[00:16:35] Dr. JB: Wow. No explanation, just to talk to her about it.

[00:16:41] Dr. Nebel: Yeah. And they hadn’t even made me aware of the fact that they had made that comment, which I think is really telling them to be quite honest, And so again, even within our field self care and acknowledging kind of where you’re at and trying to heal yourself from damage and from these experiences that really serve as a trauma in a lot of cases, how little that’s understood. And especially with a colleague that I had worked with for over 10 years. So it was just, once I explained it to him obviously there was no issues, but I think just that wasn’t a response that I had really expected. Yeah, but it’s okay. I mean, there’s no ill will, or I just think it’s sad that people don’t kind of understand or appreciate that. But that’s okay.

[00:17:34] Dr. JB: This was a fellow physician?

[00:17:37] Dr. Nebel: Yes. Yeah. Yeah. But out here in our In our neck of the woods. So I’m in Lancaster, Pennsylvania and it’s a very kind of stoic, shove everything under the rug type of a community. So I’m not surprised to have gotten that type of of a passive aggressive response, but yeah.

[00:18:01] Dr. JB: That’s very interesting when you say shove everything under the rug, because the question is what happens when you shove everything under the rug?

[00:18:09] Dr. Nebel: You get a really lumpy rug.

[00:18:14] Yeah. Yeah. Yeah, I don’t know. I have really truly made it into a new practice of not doing that. I certainly know that I would have, I have acted, much more passive aggressively in the past than I do now. But that’s part of not holding on to things for me and just letting those things go. I’m very transparent and I try to speak truth in love. Sometimes that’s hard. Sometimes that’s hard, I think to receive it as well as to give that. But I think even as difficult as that is, I’d say 9 times out of 10, the recipient will come back to say, Hey, I appreciated that or I didn’t want to, but I really needed to hear that. And I think that my patients, my colleagues, they sort of just know that I’m a straight shooter. And they really, they appreciate that. I have so many patients and caregivers who just feel like I’m, in the medical, in their medical interactions, nobody kind of gives them, oh, just nobody tells them what’s going on or they haven’t had that real conversation, if it’s about a certain diagnosis of what that looks like or how, what progression might look like They’re not fun conversations to have by any means, but since I’m in the geriatric population, I do an awful lot of end of life, kind of everything. I do work with hospice and people are always appreciative and I look at it as sharing that type of information. I think it’s necessary and it gives them the opportunity to prepare. And it’s not my place to really withhold that from them. Yeah.

[00:20:03] Dr. JB: A couple of questions and we’ll, we’ll go back to the straight shooter. You mentioned that when you were on your leave, that you realize that you really love what you do, but you did not love how you’ve had to do it. So could we explore that a little bit more? What you meant by that statement?

[00:20:24] Dr. Nebel: Absolutely. I, I really find it important to kind of meet them where they’re at. And so by that, well, and I’ll have to, I have to say that one of our– oh, patient centered care like I felt was this, and it still is kind of this buzzword that’s just thrown out but it’s not, like, I don’t feel like it’s an accurate description. And so that just kind of irked me um–

[00:20:49] Dr. JB: accurate description of what?

[00:20:51] Dr. Nebel: Of the medical community of the care that we give. Yeah. Cause I just feel like it’s a pseudonym, a pseudonym. I just feel like maybe it’s a lie. It’s just a complete misnomer.

[00:21:02] Dr. JB: Straight shooter indeed.

[00:21:04] Dr. Nebel: Yeah, I told you. Well, and so what I mean by that, so I would have patients call for I don’t know, say the urine symptoms, and so they would, the front desks by their protocol, they have to put them into a schedule and then I’ll look and see at the end of the day, this acute visit for urine has been put on the schedule and that’s fine, and there’s nothing wrong with putting that patient on the schedule, but I just, over lunch, I call the patient. I’m like, Hey, what’s going on? What symptoms are you having? How long have you had them? I’m just going to go order a urine right now so that you can go to the lab and they’ll get it started and then I’ll give you a call if it looks like we need to treat you. So that type of an example, and then I would just call the front desk and have them take the patient off the schedule. I had taken care of it. And it didn’t, it didn’t require, an extra visit for the patient. It didn’t make her wait, several more hours to have an answer to what she needed. And so, and there, there would be tons of times like that, that I really would just kind of call the patient try to talk with them and not make them really inconvenienced, I guess, to come out when they’re not feeling well to begin with.

[00:22:21] So I, and I, when I said like patient centered care is kind of a misnomer, I feel like, with reimbursement and quality measures, like it’s just become a buzzword for reimbursement. And it, it’s just another way to label that were doing different things to get more money. And so that’s just kind of how I feel about that. But other things really being patient centered for me now, when those patients would be sick or would have a really hard time coming into the doctors, but needed to be seen, you know, we didn’t have the capability of going to them to evaluate them. In, in most acute situations, where someone was too sick to come to the office, we don’t have anyone going to them. And so, their only option is to go to the urgent care or–

[00:23:08] Dr. JB: the ER.

[00:23:09] Dr. Nebel: Yeah exactly, go and see Doctor JB, and there’s nothing wrong with that, but that’s not what everybody needs. And so I think again, just meeting them where they’re at. That’s why I go into the home. So you know, other things like I’ve really valued, time. Time with patients and geriatric patients– well, and I mean, a lot of patients are complex in different situations– and then so, and those types of things take time and it really, visits get shorter, the amount of work or boxes that you have to check off gets longer. And, and pretty soon, you’re asking Mr. And Mrs. So-and-so, to come back to discuss the next couple of things on thier list and that’s not really patient centered either to me like, okay, where you have to now split this into two visits. But I get it. I mean, I completely understand in a health system what the demands and the needs are and why schedule is like that.

[00:24:05] Dr. JB: Can you elaborate on that since you’ve been on both sides? So let’s put on the other hat, let’s look at why you get it.

[00:24:14] Dr. Nebel: So like from from an administrative standpoint I mean, it really all comes down to needing to meet the bottom line. And so you need X number of patients per provider seen per day so that you can meet there, the expense for that. And then the larger expense for the practice and the system. And plus have some amount of at the end of the day. And so that’s the, that’s where most of those numbers come from, this is the average we can expect to be reimbursed per patient, and so this is, this is where you need, like, this is what you need to be. And then there’s also just the national criteria that kind of get factored into that too, just saying, I know we would always, you’re often be told this, this is the national average for a number of patients seen per day, we need to do that. And from a health system side, I think they’re mainly looking at it as being accessible to the patients. They want more visits in a day so they can, can care for more patients. But doesn’t always really feel like that is, is quite, it’s not quite as cut and dry as that.

[00:25:24] Because increasing, you can obviously create more hours in a day. And so you’re, you’re really reducing the amount of time that you have with each individual. And, and I’d often found that, if you actually have a longer visit with someone where they get the chance to ask the questions that they have Then you can probably generally, like your follow-ups can be pushed out a little bit longer. So you build in that extra time and capacity for seeing patients by doing a really thorough job when they’re there with you in the office. But if you’re kind of artificially, just quickly kind of going through that visit, you’re going to see him back, sooner than you probably expected.

[00:26:04] And with, I mean, the trend now I think is just getting patient panels so large for providers that primary care anymore is really chronic care. And then any acute care needs that used to go to private or to the primary care providers, they’re now being pushed out to urgent care. And to me, that’s not a great model for patient care either because when someone’s sick, when I’m sick, I want to talk to someone who knows me and the patients out there now. I mean, they’re not really feeling like they have that. They, they don’t have that opportunity. We’ve got local systems that are boasting about, their growth and surpassing their goals for urgent care. Well, yeah. And that’s great for the bottom line, but is that really great for the patient? Because that to me says that maybe your patient panel sizes are too big on the primary care side if they can’t see their patients things.

[00:27:03] Dr. JB: I think patients get a little bit confused too because they will go to an urgent care setting or they’ll go to the emergency departments and they will expect that the provider taking care of them knows their history and knows, like it’s in the system, read my 10,000 pages worth of stuff. That’s not what we do, right? We’re here, what brought you in today, I’m not going to go through and read all these months and months worth of different presentations to the hospital and whatnot. I don’t have time for that. I don’t, like I don’t, I don’t have that relationship with you, right?

[00:27:43] Dr. Nebel: Yeah, absolutely. And I think it’s frustrating on both. And then they’re, they’re not feeling, they don’t have a feeling of, of really being cared for, I think at the level that they were hoping for. Now certainly from a, in the medical perspective, it was completely appropriate and adequate, but it didn’t meet up to probably what their expectations were. And plus they have to you know, how long did they have to sit before they got to you? How long was that, was that wait for them? So yeah, I, I love right now being accessible. My practice, patient numbers are small and I’m still growing, but I’ve also kind of kept in mind that I am going to continually be evaluating my panel so that I don’t have to change the access or quality of care that I’m giving.

[00:28:38] Because it, I mean, honestly, like we all have that little bit of ego that needs to be stroked. And so when you have patients who call and they’ve got acute abdominal pain or something and you can go and like evaluate them at home within the hour and get their CAT scan done and figure out their diagnosis and get them treated within a three-hour period. And they’re grateful because the last time that they had an acute issue, they went to urgent care and sat for four hours to see someone they didn’t know. Yeah, I’m glad to provide that level. I’m grateful to be able to provide that level of care to them.

[00:29:13] Dr. JB: I just want to make sure I heard you correctly. That maybe this is, this is too literal, but I be like, wow, that’s amazing that, an elderly patient calls, they’re having abdominal pain. And you said three hours, you could do all that in three hours? How? How??

[00:29:32] Dr. Nebel: It was a Sunday. Yeah, like a nine to 1230 on a Sunday. So, yeah. Yeah. So that’s how that worked if it, so if it had been during a weekday I would have had to move schedules and stuff around and I’m sure imaging centers, might’ve been a little bit busier. So, yeah, so it might’ve been like five or six hours on a weekday, maybe. I don’t know.

[00:30:01] Dr. JB: That’s so amazxing because and then from the standpoint of like an emergency medicine physician, you end up having to send your, your patients and are you accessible? Like, can the doctor call you, and…?

[00:30:11] Dr. Nebel: Oh, absolutely. Yeah, they I mean, the thing that I run into, which is annoying is because I am in, I’m a private practice, I don’t have the same integration into the electronic records. And so just trying, well I’m always available. I, well, I’m always available to be called by any, I think just most of the time because of the pace and the volume that, you know, either urgent or emergency room providers are seeing patients that they just don’t have the time to call. I will often call the ER myself. Like if I’m sending someone in or know that someone is going in I’ll call to talk to the nurse or the physician, get their fax number, try to send over and sorta tee them up for as best as I can. Sometimes I don’t find out that they’ve fallen until after the fact. And then like yesterday, your demented patient gets Benadryl and Ativan, and then has to be admitted for delirium anyway, but I don’t always catch it, but oh, well.

[00:31:18] Dr. JB: Guilty. Guilty!

[00:31:21] Dr. Nebel: Yeah. Oh, if only I had talked to you, I was kicking myself that I didn’t find out sooner, but oh, well.

[00:31:28] Dr. JB: You know, one of the things that’s really interesting is, how you mentioned the whole time component, right? If we just had a little bit more time with these patients really get to the source exactly it’s going to be able to provide better care. Right? And then they’re like, oh, my doctor just doesn’t care. They don’t spend any time with me. So both ends once, spend more time with each other. What do you think, why what’s going on?

[00:31:57] Dr. Nebel: I think it’s, it’s, there’s so many challenges and just so many tasks that any providers asked to get done in a given day. I think a lot of administrative stuff probably in a, in an employed setting falls to the probably, I think probably a good amount of it falls to the provider, I would think, to get done. And so in like practicing and, and I know, a lot of times anymore, like you support staff like an ma or a nurse, if you’re fortunate enough to have one, that person might be providing care for four other physicians as well. And it’s for me, like my ratio here for the practice is one-to-one and so there’s a lot that my nurse does for me. But yeah, I mean, I think it’s really there, there are so many patients that really want that time with their provider and there’s so many providers, I would guess who really would, would like to have more time with their patients. Now, there are certainly people who think that’s just kind of not what they’re in it for and they’re just wired differently and that’s fine.

[00:33:01] But I agree, like I think it’s something that’s desired on both sides and oftentimes, time it’s not, well, patients see time as a marker of quality, of when it really probably has very little to do with it. It’s not a direct correlate. But patients don’t necessarily see it that way. Which is interesting because you could probably do very little evidence-based medicine but spend two hours with your patient and they’ll think you’re the greatest thing. So I want to be careful and cautious, I don’t believe that there a direct, there’s a direct correlation there.

[00:33:40] But one of the things I think too, being able to take that time with people helps me to get to know them better. And so by knowing them better, I can get a better sense of what is really kind of a physical somatic medical thing that I can do something about and what is really more of, more psychosomatic or more soul or more trauma based, like, because those things come out in physical ways. And I think all of us know that chronic repeat offender for whatever there’s, you can try everything under the sun from a medical perspective and still not reach that or treat them or get them to a place of healing, because– so having that time with them helps me to kind of be able to tease out what is and isn’t. And then I, with that time, have a relationship with the individual. I usually have a relationship with either their family or caregiver too. And that relationship lets me say hard, or allows me to say hard things. So that’s probably one of the reasons I can be a straight shooter with patients too, because we have that relationship and we’re coming from that place of trust. And they already know from the time that I’ve spent with them, that I really care about them and I’m not just being. So, and, but I have had cases where family asked the patient, why do you still see her she’s so mean? Because they didn’t know me, like when she told them what I said. So we’re meeting to smooth that over. Anyway, but yeah, I think the relationship is probably as a basis for being able to just kind of speak openly with them.

[00:35:26] Dr. JB: And so, you described your current practice as concierge medicine. How was that different than direct primary care?

[00:35:34] Dr. Nebel: Oh, that’s a great question. I have the utmost respect for direct primary care and that is actually how I tried to start my practice. Being a senior care and telling seniors that I don’t accept Medicaid, it was mind blowing to them. And I really struggled to enroll new patients. So then I, thank God I was within my opt back in window, and so I opted back in and so now I do insurance as well as the monthly fee for uncovered services. And so that is the difference. So direct primary care is really is the monthly fee that it varies by practice for what it covers within that monthly, or what is covered within that monthly fee. And then a concierge practice will bill insurance and also charge the monthly they’ll bill Medicare plus charge a monthly fee. So that would be just kind of short and sweet the difference between them.

[00:36:29] Dr. JB: So does concierge tend to be a little bit less expensive than direct primary since they’re billng…

[00:36:34] Dr. Nebel: Well, you’d think, but no. It works the other way around typically where the concierge is of what is more expensive than direct primary care. But, and I’d say the expectations from the patient side are probably a little different too. And that really depends on how you set up your practice. But in general, like a concierge is very much like a service- type of entity. And so I’m available 24/ 7 to my patients. They can reach me in any variety of ways that is convenient for them. They know that they can contact me and be seen outside of what typical office hours might be. And let’s see, we do, like part of our practice we have like we will just provide things to patients, like remote patient monitors. I’m trying to think, we’ve given wheelchairs before. So there’s some, just kind of add on type of things that are included. They get regular phone calls from our either nursing, well from our nurse to just kind of check in with them and see how things are going. So there’s the way that I have designed the practices. It’s a little bit different than what others might. So that’s, that’s probably a fair run down.

[00:37:49] Dr. JB: So you mentioned that you’re available to your patients 24/ 7. Well, let’s revisit that concept, and, and how are you balancing that amount of availability with not going back down the path of burnout?

[00:38:05] Dr. Nebel: Yeah, absolutely. That’s great. A lot of it is based on my patients, just kind of a mix of my patients. I have some who are kind of healthier, younger, and then I have just, I have a handful who are kind of the more complex seniors. And then the other thing would be, well, the patients themselves just tend to be very respectful. So they generally, like I say, I’m available 24/ 7 but I could count, I might, there might be one night a week that I get a phone call after six o’clock. And there are weekends that go, I’d say most weekends, I don’t get any calls. And so, some of that it’s patient makeup, and then it’s also just the, the volume of patients. And so, It’s a low volume, and that really helps with that. I’d been, when I was in the geriatric practice before, and we covered 10 plus nursing homes and every, bump, bruise, med refusal, fall gets called in. And that was exhausting cause you could be on the phone for just hours in a day.

[00:39:17] And so this is just such a different feel. It’s, it’s just not the same volume. So, there are times when, like I see the phone ring and it’s after five o’clock and I groan, and then I just kind of remind myself, okay, Kristen, you can do this. It’s part of what you’re offering. And so I would say I’m also looking into the options just to kind of have a shared or have someone who can share maybe some evenings or weekends or things. But I’ve been able to go away for a week at a time even and have access, have the patients have access to me either virtually or on the phone or email. And I, I always, a lot of that I think is accepted by the because I do a lot of education on the fact that probably 97% of what you’re going to call me concerned about can be handled remotely. There would, there certainly are exceptions and things that require an in person evaluation, but the majority of things that you’re going to have questions about, we could, if we can’t do it over the phone, we can do it over a video visit probably, and so they feel kind of reassured about that. If I’m out of town, I have a nurse available in the area who can at least go out and do an evaluation and then kind of include me into it so we can talk some more.

[00:40:35] Dr. JB: Yeah. So if my audience number and wanted to find out more about you, how can they do so?

[00:40:42] Dr. Nebel: Oh, of course. So I have a website and it is www.peaceofmindaging.com. I have a phone number which is (717) 723-8531. Those, either of those would get you to me directly. There’s a link there asking more or contacting me on the website as well.

[00:41:09] Dr. JB: And you’re located where exactly?

[00:41:12] Dr. Nebel: I’m in Lancaster, Pennsylvania.

[00:41:14] Dr. JB: And you travel where?

[00:41:17] Dr. Nebel: So I I’m, I’m still refining that. And the short answer to that would be, as primary care I will accept in Lancaster county. I can do consults outside of Lancaster county.

[00:41:31] Got it. And

[00:41:34] Dr. JB: in closing, cause our time together is coming to the end, it went by so fast. Do you have any pearls of wisdom for my listener?

[00:41:43] Dr. Nebel: Oh. Yes. I think, as I had just kind of shared, just through some of my journey, some of the biggest things that I had to take home and had to really take to heart just to prevent burnout and to kind of heal from that. One was really recognizing my worth and putting that value above work and above my patients. And I think along with that came the realization that when I was really struggling before taking time off, I really would have, like, I think most of us would have done anything, would have given however many hours were requested or required to do my job for my employer. And what I had to realize that was that when I was not doing well, I was really not available for my family. And so I had to just kind of come to that hard, recognize that hard truth that I am replaceable at work. And they’ll do that in a heartbeat. But I am not replaceable at home. My boys only have one mom and my husband only has one wife. And this is where one of my, this is one of my priorities and I need to really give it the place that it deserves. So I think it was hard to kind of realize the replaceable part at work, cause you know, you think you invest so much time there and you have your connections with the individuals there and your colleagues. But really when it comes down to it, you resign and they’ll hire someone in your place tomorrow.

[00:43:12] Dr. JB: Yeah. Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcasts ever broadcasted or prerecorded. Come learn some. Each one, teach one. I’m done.