I got three emails last week from physicians asking me how to open a DPC practice. This is becoming a weekly thing now. My blog apparently shows up in a Google search for direct primary care startup, which still surprises me because I was never trying to rank for anything, I was just writing about what I was doing. I have been meaning to write down the version of the advice I actually give now, after two and a half years of running my own practice, rather than the version I gave when I was still in the middle of it and did not know what I did not know.
The first thing I tell everyone is that opening a DPC practice is not primarily a medical project. It is a small business project that happens to involve your clinical training. I did not understand this when I started. I thought the medicine would be the hard part and the business would figure itself out because I was a smart person who had been to graduate school. This was not correct. The medicine was the easy part. I had been practicing family medicine for eight years. I knew how to treat a URI. I did not know how to write an operating agreement, choose a business checking account, calculate my true break-even patient count, or have a productive conversation with a commercial real estate broker. I had to learn all of those things from scratch, and I wish someone had sat me down early and said, you are about to become the CFO, COO, head of marketing, front office manager, and chief medical officer of a small business. The medicine is maybe twenty percent of the job in year one. Plan accordingly.
The second thing I tell people is to take the DPC practice costs seriously and then add a cushion on top. I planned for about $95,000 in startup costs and I ended up spending closer to $79,000 before I opened my doors, which felt like a win until I realized I had also underestimated my personal expenses during the ramp-up months when revenue was thin. A DPC practice does not throw off a physician-level income immediately. It takes time to fill a panel. In my case, I hit my minimum viable panel size around month seven, and I was genuinely profitable around month eleven. Those first eleven months required me and my husband to live carefully and watch our personal savings more anxiously than either of us had in years. If I were redoing my planning, I would separate the practice startup budget from a personal runway budget and keep at least six to nine months of household expenses fully reserved in a separate account that I did not touch for any business purpose. Mixing the two accounts is how people panic and make bad decisions in month five.
The third thing I tell people is that choosing a location is more important than I realized, and it is hard to undo. I spent a lot of energy comparing lease terms and square footage and not enough energy on whether my chosen neighborhood actually had the patient population that would pay for DPC membership. My neighborhood does, thankfully, but that was luck. I interview people now and I ask them to map three things on a piece of paper before they sign a lease: where my target patients live, where my target patients work, and where my target patients already drive for other errands. A DPC practice is a relationship business, and convenience matters more than anyone wants to admit. If it takes a patient forty minutes in traffic to see you, that patient will eventually churn, no matter how much they love you in the exam room.
The fourth thing I tell people is to start marketing before you are open. I waited until two weeks before my opening day to start announcing anything publicly, because I had this quiet fear that if I told people too early and then something went wrong, I would have to walk it back and look foolish. This was dumb. I lost three or four months of potential pipeline by being shy about it. People need time to hear about a practice, think about it, talk to their spouse, maybe meet you at a community event, and eventually decide to join. A good rule I give new DPC physicians now is to start announcing your practice, your values, and your opening timeline at least four months before you plan to see your first patient. Talk to local businesses. Go to Rotary lunches even though you will hate them. Put yourself on local podcasts and radio shows. The people who hear about you in October are the people who join in March.
The fifth thing I tell people is to get clear on your DPC model before you pick any technology. I spent weeks comparing EMR options before I had actually decided whether I was going to be a pure DPC practice, a hybrid practice that accepted some insurance, a concierge hybrid, or something else. Each of those models has different operational needs, and the technology decisions follow from the operational decisions rather than the other way around. A pure DPC practice has radically different billing, scheduling, and patient communication needs than a hybrid. Decide the model first. Pick the tools second. I did this in the wrong order and wasted a lot of time.
The sixth thing I tell people is to think hard about what you will do about after-hours coverage before you open, because your patients will ask. In a DPC practice, the unspoken promise is that your patients can reach you, and if you have not worked out what reach means and what hours it covers, you will find yourself answering patient texts at eleven at night within a few weeks and resenting it. I use a combination of scheduled messaging windows, clear expectations communicated at the first visit, and a cross-coverage arrangement with another local DPC physician for weekends and vacations. None of this was in my original plan. All of it became essential within the first six months. Write down your coverage philosophy before you open your doors, share it with patients at intake, and protect it like a physician protects her license.
The seventh thing I tell people is that the first panel members will be harder to find than the last ones. Everyone wants to hear this is not true, but it is true. The first hundred patients come in slowly, one or two a week, each one requiring a fair amount of conversation and convincing. The second hundred come faster, because now you have social proof and a small word-of-mouth engine. The third hundred come almost on autopilot. If you are doing the math on how to open a DPC practice and you assume a linear fill rate, you will panic in month four when your curve looks alarmingly flat. The fill rate is not linear. It is exponential with a slow fuse. Plan your cash runway for the slow start, and trust the exponential part to show up around month eight or nine if you are doing the work.
The eighth thing I tell people is to invest in their own professional community early. I almost did not go to the DPC conferences in my first year because I was too busy building a practice to attend a conference about building a practice, which is a joke that becomes less funny when you realize I really thought that way. Going to the conferences, joining the listservs, finding two or three other DPC physicians at roughly the same stage as me, and having regular calls with them was one of the highest-return things I did. The isolation of running a solo DPC practice is real. It will wear you down. A peer community is not a luxury, it is operational infrastructure.
The ninth thing I tell people is to write down your personal non-negotiables before you open, and to put them somewhere you will see them, because you will be tempted to violate them. Mine were a hard stop at six in the evening, no work on Sundays, at least one full week of vacation every quarter, and a target panel size that I would not exceed even if demand grew. I have stuck to most of these most of the time. The ones I have slipped on are the ones I did not write down, which tells me something important about how memory works under pressure. Put your limits in writing. Share them with your spouse. Read them when you are tired.
The tenth thing I tell people is that the first year will be hard and the second year will be better and the third year will be the year you wonder why you waited so long to do this. I am in the early part of year three now. My panel is stable. My income is better than what I was making at Meridian, which was the one thing I thought I would have to sacrifice. My evenings are mine. My marriage is better. My patients know me and I know them. I am not romanticizing it, there are still hard days and weeks when I wonder if I am doing it right, but the overall shape of my life is one I would not trade back for anything. If you are reading this and you are thinking about starting a DPC practice, I cannot tell you whether it will work for you, because that depends on factors I do not know. But I can tell you that the version of me who was crying in the hospital parking lot three years ago would not believe what her life looks like now, and I think that is worth something.
So that is the version I give now. Shorter than the real thing, longer than a Twitter thread, honest about the parts that were harder than expected. If you write to me after reading this, as some of you will, I will probably say most of these same things in a slightly less organized way, because that is how I talk. Good luck. Write back when you are open. I want to hear how it went.