Like Dr. Quinn, who started a community clinic and worked tirelessly to change her local community’s perception of modern medicine on the hit television show, Dr. Quinn, Medicine Woman, Dr. Julie Gunther feels passionate about her role as a family doctor. As a modern medicine woman she stands for something greater than the “7.7 minute office visit” and the “systematized approach” to healthcare we’ve all become accustomed to.
“I believe in the ideal physician archetype-- a physician that is committed to a community of people, someone who knows the stories, the heartbreaks and the adventures and participates life-long as a resource for education and wellness,” she says.
Following undergraduate work at Harvard and post-baccalaureate work at Vanderbilt, Gunther became extremely passionate about comprehensive family medicine. She wanted to work alongside patients through all of life’s stages and ages.
During her medical school interview she shared her vision to become a modern-day medicine woman. “I think they [admissions] thought I was lying!” she recalls.
Many along the way told her that the type of doctor she hoped to become no longer existed. But she had the privilege of shadowing passionate primary care physicians in rural and urban environments during her training at the University of Washington, and saw that full-spectrum primary care was alive and well.
While Gunther trained to do full spectrum family medicine with OB, she found that the practice climate in her home- town had changed markedly in the decade it took her to get from undergraduate to Board-Certified physician. “When I was in medical school, family doctors were still delivering babies at our local hospital. Four years later, practices were selling to the local hospital network and family doctors were switching to full-time outpatient work.”
Two weeks after she finished medical school, Gunther and her husband had their first daughter. Three years later, while in residency, they had their second daughter. With a young family and changed practice climate, Gunther and her husband decided that it might be better for her to work as an employed outpatient physician for the local system. They were hopeful that the commitment of ‘controlled’ clinic hours and reduced administrative demands would allow her to be a “doctor during the day and mom the rest of the time.”
For the next five years, Gunther worked as an outpatient physician and hospice medical director. She credits being well-trained in coding as one skill that allowed her to maintain longer visit times and protect her practice philosophy in the face of a 2200 patient panel and the numerical requirements of her RVU-based contract.
Around her three-year mark, however, Gunther realized she had to do something different. An esteemed senior physician left clinical medicine. Another partner, a physician she feels embodies what it truly means to be a compassionate healer, was “eaten alive” by the administrative demands of outpatient work. She describes the regularity with which she found herself apologizing to patients for being late, and her feelings of frustration at not being able to deliver on commitments because of staff turnover at the clinic. “I realized that being an employed physician eliminated every bit of what had inspired me to become a family doctor in the first place...My name was on the door, but I had no real say in the day-to-day operations. I couldn’t look my patients in the eye and make any sort of commitment about access, follow through or any other administrative matters. My greatest skill became typing. I had 3-5 hours of typing and clicking to do daily. I typed at night, on the weekends… so much training and so much time and my best skill? Typing. I felt badly every day. I have always known what kind of doctor I wanted to be… what kind of practice I wanted to build.. and this just was not it.” She knew something had to change.
The Turning Point
When Gunther describes her decision to change the course of her medical career she tells the story of one of her favorite patients. She calls him “her last domino.” After watching him suffer during the last 6 months of his life, due to what Gunther calls “repeated failures of our healthcare system to know the whole story, follow through on information and to truly, individually, take care of him as a person”, she decided that she would no longer sit on the other side of the desk and apologize for something she no longer believed in.
“I decided, metaphorically and factually, I wanted to sit next to my patients and navigate this together.”
Gunther and her husband went on a cash budget to get an accurate understanding of their spending. With $200,000 in medical school debt, two small children in pre-K and their first ‘fancy’ house, they realized that their expenses were too high for the risks they wanted to assume. In the spring of 2012, they sold their home and a truck and traded in their cars for more affordable vehicles. Gunther started looking for ways to augment her income. These adjustments allowed them to reduce their monthly expenses to make the prospect of starting a small business feasible.
In 2013, Gunther attended a break-out session at the AAFP Scientific Assembly in San Diego with Dr. Josh and Dr. Doug, the founders of Atlas MD. It was her epiphany moment. “Atlas’s model incorporated everything that had been rattling around in my mind. The final piece of the puzzle was the direct fee...removing insurance billing from primary care.” Beyond inspired by Atlas MD’s Direct Primary Care model, she recalls tape-recording the session and calling her husband to tell him that she was starting her practice now.
Gunther laid the groundwork for her new practice. She renegotiated her employed contract to allow her to work during what she calls the “off-hours.” She separated her outpatient family medicine role from her hospice duties. She found an urgent care job locally that didn’t conflict with her employed responsibilities and worked there on weekends and days off.
Initially, Gunther envisioned very tightly controlled start-up costs with a small, leased ‘beginner’ space for her DPC practice, ‘sparkMD’. She quickly decided that it made more sense to buy a building. “I wanted complete control…. or as much control as I could possibly have. If I can control costs, I can control pricing.”
In February of 2014, she took ownership of a small art deco building in downtown Boise, Idaho. She quit her employed outpatient job three months later. She had planned to take a month off to get sparkMD off the ground, however a long-time patient broke his hip and his family called from the hospital for her to assume care. sparkMD had begun. Renovations on her building were not yet complete, so Gunther began seeing her first patients in a 200 square foot space in the back of her building, a space that she jokingly calls “my back-alley medical clinic”. In September 2014, sparkMD opened in its renovated 2100 square foot space.
When it came to deciding what services to offer her patients, Gunther says she’s a big believer that you should try to put everything you can under your roof “within the boundaries of your board certification, training and capability.” sparkMD offers a comprehensive list of free and low cost services that include physicals, pap smears, diabetes and hypertension management, minor dermatological procedures, pediatric care and more for a flat monthly fee. sparkMD also offers same-day and next-day appointments, after-hours access, 24/7 on-call services via email, texting, face-timing and home visits. sparkMD maintains an in-house pharmaceutical dispensary with about 150 medications available to members at very low cost. “If I can save people money, I do.”
It’s been 9 months since Gunther officially opened the doors to sparkMD. Growth has been steady at an average of 30 patients per month. In March, sparkMD’s revenue reached the threshold necessary to cover all of it’s own expenses. Gunther plans to execute her first paycheck this month… for $60. She continues to work 3-5 urgent care shifts per month and ten hours weekly for hospice to support start up.
As sparkMD grows, Gunther envisions investing that revenue back in the business by adding services. She relies on her patients to let her know what is most important to them. The same is true of her process to decide which direction she’d like to go with her future learning. Among the services she hopes for sparkMD to offer in the near future are physical therapy, counseling, further in-depth lifestyle management and more procedures. She’s is looking to add providers who are strong in areas where she is not and is in early discussion with three MD’s who are interested in moving to direct primary care.
Gunther’s number one piece of advice for providers who are considering the Direct Primary Care model is to figure out your goals.
She says somewhat facetiously, “if your goal is to make a bunch of money, be honest with yourself, and create a model that’s about revenue.” And she continues, “if your goal is to liberate yourself from the constraints of modern medicine, then liberate yourself… I was told at a marketing meeting that ‘a brand is a promise’. So, figure out what your promise is, own it and make it work.”
For Gunther, her goals were to liberate herself from the administrative minutiae that were destroying her love of being a doctor, to be directly accountable to her patients and to restore the dignity of the physician-patient relationship. “I have financial commitments to my family-- because of debt, the commitment and time of becoming a doctor, etc..if I could make the base pay I was making working for the system, but turn the entire model on it’s head, then that was a win”. This meant building trust with her patients by giving them the time and space to disclose their health concerns. “I wanted an open, comfortable, welcoming space… and I wanted time… time to be the doctor I set out to be.”
Gunther recommends starting with a business plan. In the case of sparkMD, Gunther downloaded a business plan template from Fortune Magazine and took the process of writing her plan very seriously. For those who aren’t comfortable writing a plan themselves, Gunther recommends enlisting the help of a small business group, the local SBA office, or looking into small business start up resources at a local college or university.
Her number two piece of advice is the need to jump in.
“There comes a point when you’re on the cliff and you have to jump,” she says.
Once the groundwork has been laid, money has been saved, and your business plan has been written, you just need to get started. Gunther truly believes, that when you’re doing what you’re supposed to be doing, things just fall into place. She likens it to bodysurfing, the feeling when you “hit the wave just right and it just carries you.”
Lastly, Gunther says the best form of marketing comes from providing exceptional service to your first 60 patients. “Show your patients through your actions, your response time, access… show them you’re different. When you take really good care of your first patients… that’s the best marketing any small business could have.”
Her Vision for Direct Primary Care
Gunther believes DPC is in a unique position to make an amazing difference in the American healthcare system. In order for this to happen, Gunther says, physicians need to start supporting one another and working together.
“We are so hard on each other and on ourselves,” she said in describing her opinion of physician culture. “We’ve got to start working together and treating each other with respect. Dr. Josh Umbher told me, ‘the advancements of this profession were made on the backs of those who came before us’. I agree with him. We need to get back to where we are unified as physicians. Where we are proud of what we do, who we are and what our profession has to offer.”
Gunther believes that innovative models and ideas that push the profession forward should be shared. In the case of sparkMD, Gunther openly shares her learnings with other providers. “Direct primary care has restored me, very rapidly, to loving and being proud to be a physician. It doesn’t feel like a sacrifice when, in the end, you get to love what you do. I love being a doctor again.”