Welcome to the Art of medicine, the program that explores the arts, business and clinical aspects of the practice of medicine. I'm your host, Doctor Andrew Wilner.

Today, I'm pleased to welcome Doctor Cara Pepper. Doctor Pepper is a physician coach who helps doctors transition from unsatisfying employment to starting their own practices.

In a minute, we're going to discuss whether it's really feasible to start a solo practice in 2025. Challenges include declining Medicare reimbursement, expensive medical record systems, high staff overhead, government regulations, and more.

But first, a word from our sponsor Locum Story A.com. Locum story A.com is a free, unbiased educational resource about locum tenants. It's not an agency.

Locum story answers your questions on their website, podcasts, webinars, videos and they even have a locums one on one crash course. Learn about locums and get insights from real life physicians, Pas and NPS at Locum story.com.

And now to my guest welcome, doctor Cara Pepper. Thanks for having me. Doctor Pepper, thanks for joining me. I was a little surprised of your mission, you know, helping physicians start in solo practice.

So before we get into that, just tell me, what's your medical background training? Yeah, I'm a primary care internist in Atlanta, Georgia. I work for big corporate owned hospital and practice for the first 14 years of my career, and then stepped out about three years ago and built a telemedicine practice that evolved into an in-person practice.

Now licensed in 17 states, 90% is eating disorder care, which really means I solve questions that a lot of people don't have answers to. And, I help other physicians figure out how to be happy and fulfilled in their careers in medicine.

So a little bit of everything, which I enjoy. How, enterprising. So I'm going to take a wild guess here and suggest that your years in corporate medicine were not satisfying.

You know, it was the right place for me at 30 coming out of residency, right? We are basically handed to ideas. You can work in pristine ivory towers of academics, where you can go be one of those other doctors who are selling their soul and corporate medicine.

And I didn't really like either one of those options, but I found a practice where I could teach and have autonomy and happen to be in private practice. It was the right practice for me at 30.

But interestingly, when they interviewed me, they said, we want to hire you and retire you. In other words, we want you to come and work here productively for 30 years.

And I was terrified. Something visceral and me was just like, oh, I cannot imagine doing the same thing for 30 years. I want to grow. I want to evolve.

But I took the practice job and I'm grateful I did. But every two years, I just kept feeling like there was an itch that needed to be scratched. I was now change my focus.

I change my hours. I would change my schedule. I would get an extra certification. I kept just thinking if I could fix myself, I could feel okay here.

And then I burned out because I was over working and took a sabbatical at about year seven. Came back, kept rearranging deck chairs on that Titanic, as I like to say.

And then Covid happened, and it was really clear to me that I could be dead in a week and I would regret over working the way I was. And I built our telemedicine line of service prior to the pandemic.

And then obviously it became a big thing during Covid. And I said, I need to find a way to create a practice of sustainable for me, and that allows me to have time with the patients I really want to take care of and have a special heart for people who feel marginalized by our health care system, and I wanted to build a practice around that.

And so I did. And so it's been an amazing journey. I everyone said I was brave. I certainly did not feel brave. It felt terrifying and uncertain. And, unfamiliar.

But I found a really amazing community of physicians who are doing the same. And it's been a really incredible way to reclaim health care and to really take care of patients and ourselves.

That's pretty exciting. That's pretty exciting. I'm sure there are a lot of naysayers, along the way. And, I know and I tried to do different things. People go, oh, what are you going to do that like?

Because doctors, I was in private practice at the time, pretty much, you know, have their nose to the grindstone, show up early every day, work late every day.

They don't really have a lot of exposure to life outside of what they do. So they're not really in a good position to advise on life outside of what they do because, most of them don't really know much about it, which is not a criticism.

It's just sort of an observation that one of the things that happened to me when I sort of took on different roles, working locum tenens, was that there's a whole world out there with people doing all kinds of different things that I was never aware of, because I was waking up early and working in my office all day and going home late, so I didn't have any exposure to that sort of entrepreneurial and alternative approaches to the practice of medicine.

So I think it is a scary, thing to try and start something new. Is that is that what led you into coaching? No. My own burnout is what got me there. I, before long before I was a physician, I was a professional ballet dancer and brought all my perfectionism and imposter ism and workaholism with me.

And when I burned out, I felt like a total failure. Like everyone else's. Keep our act together. What's wrong with me? And so I'd been seeing a therapist for many years, and I found a coach.

I was like, I just need a different way to try to hack my brain. And something really clicked for me in that relationship and the skill set and kind of forward facing skills that we use.

And so I was sold. I thought it was great and I decided to become a coach to help my patients because that helped me so much change my behavior. Like, of course it can help my patients.

And in the aftermath of that, a lot of physicians kept coming to me like I had the answers because I'd stepped off taking a sabbatical and started looking at medicine differently.

And so I started helping physicians through some of those same issues burnout, perfectionism, and charting. And then, you know, this is my seventh year coaching.

So that is really evolved. Then as I reinvented my entire career, people kept coming to me saying, hey, maybe you can help me figure out how to be happy in medicine, too.

Whether they leave their jobs or stay in it or create something new again. Anyone who's still practicing medicine right now still wants to do it in a sustainable way.

So people are looking for answers, and coaching is one of the tools that we can use for them. Did you go to, coaching school? How does that work? It did. Yeah, there are many.

There are many, many out there. And for that, the, A+ student and all of us, we want to get a diploma on the wall that says, hey, we've gotten this certification.

So there is, there are many programs that are actually geared directly towards physicians. And I chose one that, was 100% physician led and physician participants, and we got certified.

Clapton's amazing. I interviewed a woman, Heather Falk, who, it was a dermatologist and transition. It was not working for her private practice. She was wanted to help people more than somehow she was able to, with the constraints of the system, and did some soul searching for a while in a cabin in the woods, and finally, settled on, coaching.

And she helps, I think her her sites, I think physician crossroads white coat, crossroads or something like that, where, you know, physicians who are kind of stuck, you know, talk to her and try and become unstuck.

Not necessarily to leave medicine, as you say in your own situation. You tried other formulations. So I've been doing this for two years. What if I rearranged my schedule and tried that, you know, to work within the system, you don't always have to, jump the Grand Canyon to get a new start.

Although ultimately, it sounds like those little fixes didn't really work for you. And I think, you know, Covid was a wake up call for a lot of people, regarding their own mortality.

And it certainly generated a lot of books. I know I've interviewed quite a few people on this program who's, When I asked them. Or when did you find time to, write your book?

It was, during, Covid. Yeah. So, very interesting. Now let's get back to solo practice. You know, when I was a medical student, which was, you know, last century, a long time ago, that was pretty much what you want it you aspired to.

You're going to maybe you have a couple partners, but you know, you would settle down somewhere, as you say, you know, from the beginning to the end. You would adopt a community.

You would try and develop a reputation so people would come to you and that other physicians would respect you and refer to you, and you would invest in that community, emotionally.

And also economically. You'd probably buy your building so you could lease it to yourself and, you know, try and make, a life out of your practice within that community.

That was the model. And that model has certainly become less and less. Of course, it was always academics. And then there was, you know, corporate medicine, like, you know, pharmaceutical companies and stuff like that, which were pretty low on the desirability list.

In terms of our professors and what one should aspire to. But, oh, that seems to have evolved so that the solo practitioner option is, really shrinking by the day.

And yet you have an argument for that? I'm very eager to learn about that. Yeah. I I'll preface all of this with two things. One is that I never, ever pictured myself as an entrepreneur.

This was never part of my vision coming out of residency. And in some ways, I think I needed to go and see corporate medicine for what it was and the support that it offered me out of training, but also to recognize, like the only people who are winning are insurance companies right now, insurance companies and perhaps pharmaceuticals and perhaps hospital systems.

But as the squeeze is getting tighter and tighter with corporate medicine, with Medicare reimbursements going down and the cost of goods and staffing and all of that going up, we're really reaching a breaking point where it is so cost prohibitive to be a part of these systems, especially ones that are not nimble, who are not willing to adopt new technology and not willing to be attached to things.

It's actually a lot more cost effective for physicians to start their own practice with a very lean practice model in novel settings, and using and leveraging technology that exists.

I am in all capacities. It's actually pretty cheap to start a practice in many ways. And so as a consumer of health care and, married and have two children who have chronic illness, and we maximize our out-of-network out-of-pocket deductible every year, we spend a lot of money on health care.

And I know what it's like to spend $500 to be in a room with a physician for five minutes and not have your questions answered, even with my privilege as a physician.

And so I can offer services to patients for much, much more effective pricing, and they can get what they need when they're not paying for this massive overhead.

So I think re looking at the pendulum, the swing back and physician setting, I will no longer be willing to practice the way that I am. I want to be able to deliver care that my patients deserve and that I deserve to practice.

Whether they're looking at cash based models like direct primary care, specialty care, whether they're taking insurance, but just building very lean practice models, and leveraging virtual assistants and people all over the world to run the practice.

It's been really amazing to see what is possible when we let go of what we thought medicine should be. And I think that's part of the resistance, is that people don't recognize the sunk costs that they have.

I've put in all this time and energy into building this corporate. They own practice. If I leave, what does that mean for me? And at the end of the day, you are never stuck. What?

You are not changing your choosing, and you can choose to stay in the practice where you are. But you need to understand the cost of staying. And for me personally, that was my sanity, my family time, my delivery of care, and the skills that I built.

I couldn't even use them to take care of patients all my patients deserved. So I just wanted to build something from scratch because you didn't have time with each patient to direct, to do what you needed to know.

There's no way. And I mean, we've never been at a juncture where patients feel so betrayed by our health care system. I mean, one needs to only listen to the news or go on social media to hear patients say, I feel so betrayed by my physicians.

They never listen. They don't care. They're just in it for the money because we're the face of health care. Yes, we all know that. We all know where the money's going.

And so patients feel betrayed and we are quite literally dying at four times the rate of suicide compared to the national average. Trying to keep trying to make these things work.

People are trying desperately to take care of patients. And so closing that gap in the system as it exists is perfectly designed, and that it is perfectly designed to make money for insurance companies not to close that gap.

And so we get to decide, do I want to be part of that solution? And I think a lot of people going into private practice right now, that is what exactly what they are trying to do is to heal themselves and to heal their patients.

It's a little grim, but, I think there is a reality, to that, to your observations and yeah, you know, I've practice locum tenens, off and on for many, many years.

And for me, it was a way to obtain some work life balance and control over my schedule. And it's kind of been a shock to me that, but I think it's symptomatic of what you're discussing is that locum tenant has experienced a huge growth because the traditional options like the one you took when you finish your training, are just so unattractive that doctors say, well, you know, that just isn't that exciting to me.

I'm going to work Logans for a while until I figure out what I, what I really want to do, or I'll just do that forever. I that's one type. Of course, that locums doesn't give you any, equity.

Right? You're not building your own practice. You're just kind of you're a pinch hitter. You know, I, I use the term, substitute teacher. You know, when you're in school and all of a sudden, you know, Mrs.

Burke wasn't there that week because she was sick or, you know, out on maternity leave. Some other teacher would show up, pick up the ball. It wasn't an easy job for that new teacher.

And I stress that with locums, it's not an easy way to keep, moving from place to place and creating new relationships with, people and EMR and hospital systems.

But it does kind of, get you out of the, review, scenario where you're paid by the hour and you have a set obligation, and you do it and you're done, and that's it.

So, yeah, but I hadn't heard that creating a solo practice. So it's interesting, the program actually, just before yours, we discussed, I and a new, ambient, I note taker.

A scribe and automatic scribe. Because hiring a scribe. Well, there's overhead again. It's read, this this thing, you just turn it on, and at the end of it, it organizes your random conversation into a note, and it will integrate that into your EMR.

And, you know, you have to read it, make sure it's right, but it saves, retyping it and all that, you know, nonproductive productive time. And I was really impressed.

I did a demo on it, earlier. And it actually works. So tell us some of the other kind of new ways to lower your overhead. Right. So the biggest cost for, most practices in staffing and salary lines, benefits if you offer them.

So any and many of that, particularly front office jobs that people are having trouble staffing is because there's such staff turnover and people are moving for a variety of reasons.

So long story short, is anything that a human can do that's not directly invested in the face to face care with patients, you can look for solutions to offer that with technology.

So scheduling like my patient self schedule, there's not someone answering the phone and sitting there for 20 minutes going through your insurance information.

You literally just go to my website and schedule your own appointment and click and you're done. All kinds of billing can be taken care of with the use of revenue cycle management.

Companies and I at this point, you mentioned that there's, virtual scribes, which there's many of them on the market. They're getting built into EMR at this point.

So offloading that so you don't have to hire someone, really looking at any system. So even if you're going to have people who are answering the phones, do you need to buy out office space that has an office for someone to sit there in person with you to answer the phone?

No, I mean, people can be on the other side of the planet answering the phone for a fraction of the cost that we pay. So really looking at the staffing model, what are the things that you truly need a human with that high touch to do?

And for people who want to build a practice that is very high touch, you can do that. It's just the cost has to come from somewhere. So not to say the math ain't nothing like it.

It's just math. So you could charge patients $1 million a year to be a part of their practice if you want, but that's going to have a very different service line than someone who's paying for a quick and easy in and out.

So front office work, phones, notes, billing, particulars. You're taking insurance, then? Ways to get that information so that you can get appropriately reimbursed as fast as possible.

AI is really stepping into that space, which is amazing. Even prior authorizations. There's AI that's doing that now, which is awesome. That I would like that.

You know, I've been around long enough to. So I'm thinking about this to witness an evolution. When I, started private practice, the way that I took notes, which I thought was fantastic, was I just dictated a summary of the patient visit often right in front of the patient.

And then there was a little tiny cassette, and I would put it on the counter, and a woman would come in and pick it up and go to the back room. There were four ladies in our practice, and all they did all day was type things.

Occasionally they'd leave a blank because they couldn't understand what it was, and I'd review it and it would be done. It would take about 24, 36 hours to get it.

Then someone would print it and put it in the chart. And then I remember they started with these companies offshore, you know, in India and Philippines, where it's about a 12 hour difference.

And they had people there who had, you know, they'd upload it to your transcript, your tape to the cloud, and then these people would type and get it back to you by the next morning because of the 12 hour time difference.

And, probably a few more errors because often English wasn't their native language, but somehow they, you know, they muddled through. But it was done a lot quicker and cheaper of course, you know, per line.

And and the next step was sort of Dragon dictation. You could try it yourself. And that does work well in some instances, like for radiologists. Medical notes still a little rough, I think.

And now we have these, virtual scribes. So it's it's a really interesting, you know, evolution to see that. I guess the moral of the story is things don't have to be the way they were, right?

Well, they can't be the way that they were, nor should they. Our patients deserve better. And so to we like our system right now is not working. So it is on us to use our amazing creative, problem solving brains to advance medicine to a place that creates sustainable, efficient systems.

I mean, we used to reach people for a living, and we finally got the idea like, that's probably not the best patient care, right? This evidence is not working.

Our technology has evolved. Our understanding of physiology has evolved. Why shouldn't our practices evolve? And so, I mean, even just with that one example of note taking, I mean, for me, I'm I'm done with my notes 100% of the time.

As soon as I walk out of the room with a patient because there's no reason they shouldn't be. There's efficient systems that we can be using, which can be great.

I, as you had asked, about other ways that people can reduce their overhead. I mean, I think looking at corporate space, that physical space of an office is another really good example of that.

I mean, I'm here recording with you in my home office, and I do telemedicine, which is an amazing adjunct to direct patient care. So, I mean, I don't need office space for that, but my current office is literally one room shared space with other, health care practitioners, and we share a lobby.

I don't need a massive office building in order to deliver patient care. I mean, I've been double booked many, many times in the past. I assure you, I cannot be in more than one room at the same time.

So I don't need five rooms to deliver care. Just me and the patient. And that tends to be more efficient. But you're seeing people look at novel spaces outside of healthcare, you know, sharing space with attorneys, renting single rooms, even using, like, like, we work like commercial spaces to, like, rent by the hour if they are building a practice, they don't need to, like, invest in real estate in that way. So I would encourage any of your listeners who are remotely curious about this to just if you could just wipe the slate clean and say, like, how would I love to deliver care, what would that look like?

What would the pace be like? What would it feel like? And just imagine all the different ways that they could do that. Like you get to create this. Really the only thing that sense tone is you need some malpractice insurance.

But outside of that, you can rewrite the script entirely, which is really exciting. All right. Great moment for you to tell us how to get in touch with you.

In case anybody's interested in remember my name, you can find me. My name is Kara. Okay. Kara pepper. So my website is Kara Pepper. Indeed.com. Every social media outlet, it's Carol Pepper.

Andy is my handle. And if you want to send me an email, it's hello at Kara Pepper indeed.com. Very easy to find. And I notice there are some free, you call the master classes on your website. What are those?

Yeah. So they really are geared towards physicians who are feeling stuck. So I do a lot of work in the perfectionism, imposter syndrome, burnout space.

But also, if you're just curious, like, and maybe I want to start a practice, but it just feels overwhelming and really expensive, like there's master classes for just that.

In fact, one master classes is all the mistakes I made as I was starting my practice. Like I have no secrets. I'll tell you how to not make the same mistakes that I made.

There's stuff on there too, so there's all kinds of blogs, blog postings and articles. I have a podcast as well that teaches about this stuff every week.

And then there's masterclasses. If you're a video person and you can find me on YouTube at Kara Pepper, M. D. so tell me a recent success story. They called you.

They said, I'm fed up. I don't know what to do. I'm working so hard. I got to do something different. You said I could start my own practice. I can't imagine it.

And then they did, and it worked. Is there such a person? There are many, many of those people. It's interesting to me that people call me at a variety of stages.

There's this very predictable process that people get up through as they are considering launching. And the first is, is where most people call, which is just I'm miserable in medicine and I don't know what to do.

They haven't even really considered opening a practice, but it's that recognizing that you have a voice and you have autonomy, that you are not a prisoner of your job, and that you can create something new.

And that's really a process of internal transformation. So people the chief complaint is often I'm burnout. Let me dig down into that. And then the next stage is really just discovery centers wiping the slate clean.

So what does that look like? How do you just reimagine what that looks like? And it's really interesting, this idea of a portfolio career is becoming more and more common.

And in some ways, that's what you have had. You know, you've done locums, I've taught your podcast. You probably have other you are a dive instructor.

I understand you do all kinds of things that you enjoy doing and that together compiles purpose and hopefully an income for you to do those things. And so I think many people go through a about two year transition period where maybe they need to do locums while they're building a practice on the side if they want to self-funded, or maybe they need to stay in their job, but they need to create some space so they can even just get curious of what that looks like, or to engage in a side business that they've been dreaming of.

So to answer your question directly, there's I mean, I have a number of, particularly OB GYNs who are really devoting their career now from traditional RPG way and care to menopause care.

So they're building really amazing, very targeted communities around women's health and midlife. And so I have some that have built only telemedicine, others have built comprehensive GI and practices.

Other others have gone on like speaking tours. I want to do a lot of coaching and community building. So that's been really exciting. I've got a client who's built three.

She transitioned from emergency medicine to, kind of a wellness cosmetic space, and now is on her third office that she's built in her little community.

I've got, traditional internists who do sleep and do hospital medicine and outpatient medicine. We're now building direct primary care practices geared towards metabolic health and sleep health.

It's just really I think the common theme with all of these folks is that they desperately want to have purpose and meaning in their life and to to use their skills to take care of patients.

And they just want to reimagine what that looks like. And so you can build it, which is really exciting. So I feel like I've kind of opened the door into a world that I didn't know existed.

I mean, you know, there are always people out there trying new stuff, but it sounds like there's a lot more of them than I realized, and that the success is possible in a non traditional role.

And as you say, that's that's kind of what I've done along my career, although I would never necessarily recommend it. It was just something I needed to do for myself.

And a lot of balancing with purpose and income. And, you know, there's a lot of decisions to make along the way. And frankly, I didn't have too many role models, to, you know, look for, for, help in, making those decisions.

So maybe there will be, more. I was going to say that is my number one piece of advice for colleagues. We often get stuck in watercooler talk. You know, you're busy and patient, and so you lean over to the person in the touchdown next to you and you're like, oh, that's hard case today.

And we're often just stuck with folks. We're doing the same thing that we are, and we just subconsciously think that's just what we do. That's just how medicine is.

And so getting outside of your echo chamber is critical, whether that's getting outside of medicine entirely and just listening. You know, there's an NPR podcast app called how I Built This.

And well, before I even burned out the first time, I would listen to this podcast, because I would listen to the Mark Cuban's of the world talk about how they're tinkering in their garage and had this idea and then it just built in, you know, before you know it, they've built something really amazing.

And hearing that helped me understand that there's so much more outside this, like, sphere of medicine that I'm a part of. And even within the world of medicine, get out, go to a conference, start listening to podcasts like this, listen to people who are doing things differently because it will spark something.

If it's just possibility that you don't have to stay the way you are, you can continue to evolve your career. My husband is an MBA and we met in college, and if he still had the same job that he had when he got out of his MBA at 27, people would think there's something wrong with him and they like, have you not grown or you do you have no ambition?

Are you literally still 27 years old? And what you want in your life? And somehow we're expected to be hired and retired and stay in the same job for 30 years.

And I just give your listeners permission is just like getting unstuck as a sign of personal growth. It's not that you're failing. There's nothing wrong with you.

Just get outside of the bubble and listen to other people who are doing it. You never know what hangs in the balance of that. And I'll add and correct me if I'm wrong, that, failure is is okay.

Yes, absolutely. I mean, the best things in my life have come because I failed at something that I tried to do. I mean, it stinks. I hate failing, it's not fun.

But listen, I have to learn things the hard way. And when people say to you, do you miss your old practice? No, I don't miss it. But I also don't regret it.

It's what I needed to do and see how medicine was built so I could deconstructed, burn it down, create something new for myself. I wouldn't have known that unless I tried it so it's painful, but it's necessary.

Sometimes. Yes. I'll just add that, not all traditional physician jobs are terrible, and there are people out there in, classical jobs who are doing fine and not burnt out and happy.

But there are way too many physicians who are not satisfied with the status quo. And I think it's really great news that there are opportunities and people like yourself, kind of have created them and are willing to teach others.

And I'll add, one of the reasons I do this podcast is I do look for people who are doing things just a little bit differently, whether it's, writing a novel or starting a company, just to kind of, you know, they never make page one of The New York Times, but, you know, they're buried in the back somewhere.

But, their efforts are really meaningful. And deserve to be, highlighted. So that's that's part of my purpose here at the Art of medicine. So I'm so pleased to have you on the show.

Thank you for having me. And thank you for just showing people what's possible. That's, It's the see one do one, teach one thing that we talk about in medicine.

It's exactly that. Thank you for doing it. Yes. Okay, so we're going to wrap up. Is there anything you'd like to add before we close? I think I just said it.

I think, anyone who's still in health care is here for a reason. And creating a life around that reason, I think, is one of the greatest challenges and rewards of our career.

So whatever you value, lean into that, because that is something that you can make a life out of and a living just great. Doctor Kara Pepper, thanks for joining me on the Art of medicine.

Thank you. And now a final thanks to our sponsor Locum story.com. Locum story.com is a free, unbiased educational resource about locum tenants. It's not an agency.

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Success in Solo Practice! An Interview with Physician Coach Kara Pepper, MD

Andrew Wilner, MD, FACP, FAAN

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