I need to talk about something that has been living rent-free in my head for the past three months. Verdant Family Medicine has a waitlist. Not a theoretical "we could probably add more patients" situation but an actual list of forty-seven people who want to become members and cannot, because I am full. Forty-seven people who heard about us from existing patients, who called or texted or filled out the inquiry form on our website, and who received a polite reply from Sarah explaining that we are not currently accepting new members and offering to add them to the wait list. Forty-seven people I am turning away from the kind of care I built this practice to provide.
That number haunts me a little.
The obvious solution, the one that everyone from James to my DPC physician group to the guy who delivers our office supplies has suggested, is to hire a second provider. Add another doctor or a nurse practitioner, double the panel capacity, serve more patients, grow the revenue. It is the logical next step in the standard small business playbook, and on paper, the math works. Another provider billing at even 70% of my current rate during their ramp-up period would more than cover their salary within the first year. James has built the spreadsheet. It has twenty-three tabs now. The man cannot resist a good financial model.
But I have been hesitating, and I want to work through why on the page, because I think other DPC physicians face this same inflection point and the decision is more nuanced than the growth-at-all-costs narrative suggests.
The first reason I hesitate is philosophical. I started Verdant because I wanted a practice built on a deep, personal relationship between one doctor and her patients. Every patient in my panel knows me. They know my voice on the phone, my handwriting on the rare paper form, the way I explain lab results, the questions I always ask. That continuity, that singular relationship, is not just a nice feature of the model. It is the model. When I add a second provider, some patients will see that person instead of me, or in addition to me, and the character of the practice changes. It is no longer "Dr. Chen's practice." It is a small group practice that happens to use the DPC model. Those are different things, and I am not sure the difference is one I want.
The second reason is operational complexity. Right now, Verdant runs with breathtaking simplicity. There is me, there is Sarah who handles front desk and medical assisting, and there is the technology that fills in the gaps. The decision-making structure is: I decide. The communication structure is: I tell Sarah. The conflict resolution process is: I think about it in the shower. Adding another clinician means scheduling coordination, coverage arrangements, shared patient protocols, credentialing, malpractice for two, potential disagreements about clinical approach, and the thousand small frictions that come with any professional partnership. I have worked in environments with those frictions, and escaping them was part of why I left corporate medicine.
The third reason is financial risk. Yes, the spreadsheet says it works. But spreadsheets are not patients. A second provider needs time to build their own panel, and during that ramp-up period, I am covering their salary from existing revenue. What if the ramp-up takes longer than projected? What if the new provider's patients have higher attrition because the relationship is newer and less established? What if, and this is the scenario that keeps me up at night, the new provider and I discover after six months that our clinical philosophies are incompatible and we part ways, leaving me with disrupted patient relationships and a financial hole?
James, ever the accountant, points out that I could mitigate the financial risk by hiring a part-time nurse practitioner rather than a full physician. Lower salary commitment, more manageable ramp-up, and I maintain clinical oversight of all patient care. He is not wrong. But a part-time NP creates its own complexities: patients who want to see their provider cannot always schedule with someone who works three days a week, the NP needs supervision time that comes out of my clinical schedule, and the DPC membership model gets complicated when patients are paying for access to a physician and sometimes getting an NP instead.
There is another option that I have been thinking about more seriously: simply not scaling. Keeping Verdant exactly as it is. One doctor, one MA, a full panel, a waitlist, and a practice that runs with the kind of focused simplicity that makes my work sustainable and joyful. The waitlist is uncomfortable, but it is also, if I am being honest, a kind of validation. It means the model works well enough that demand exceeds supply, which is a luxurious problem to have after two years of wondering whether anyone would show up at all.
I have been talking to other solo DPC doctors who faced this same decision. Their experiences are mixed. One physician in Colorado hired an NP two years ago and says it was the best decision she ever made: her practice serves more patients, her income increased, and she gets every Friday off. Another physician in Virginia hired a second doctor, had a philosophical disagreement about chronic pain management six months in, and went through a painful separation that cost her eleven patients who followed the departing physician. A third simply stayed solo, maintained a waitlist, and reports being perfectly content with the arrangement. There is no universal right answer.
What I keep coming back to is a question that James asked me last week, with the quiet precision of a man who has been thinking about it for a while: "What would make you happiest?" Not what makes the most business sense. Not what maximizes revenue or patient access or community impact. What would make me, Sarah Chen, the person who cried in a parking lot three years ago because she had forgotten what it felt like to love her work, happiest?
I do not have the answer yet. But I think the fact that the question is about happiness rather than growth metrics is itself a sign of how far I have come. In corporate medicine, nobody ever asked what would make the physician happiest. They asked what would maximize RVUs. The freedom to prioritize my own wellbeing alongside my patients' care is perhaps the most radical thing about this model, and I do not want to make a scaling decision that compromises it.
I am giving myself until the end of summer to decide. In the meantime, the waitlist will grow, and I will continue to provide the best care I can to the 348 patients who are already mine. Next month, I want to write about something more practical: the nuts and bolts of managing a full DPC panel, including how I handle the volume of between-visit communications, the art of the thirty-minute visit when you have twelve per day, and the systems that keep things running smoothly at capacity.
For now, if you are a DPC physician facing the same crossroads, I would love to hear what you decided and how it went. This is one of those decisions where lived experience matters more than spreadsheets, even really good spreadsheets with twenty-three tabs.