Lean Out Podcast

Micropractice with Kara Pepper

• Dawn Baker • Season 2 • Episode 35

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In this episode, Dawn Baker talks with Kara Pepper, internist and micropractice pioneer who specializes in eating disorder care. Kara is also a life coach who specializes in helping other physicians start and manage their own micropractices. 

Kara discusses what has happened since her last interview, why she decided to add an in-person arm to her micropractice, how she closes her stress cycle, and more. 

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Welcome to the lean out podcast. I'm your host, Dr. Don baker. Are you looking for a new approach to finding authentic and sustainable work-life balance? You've come to the right. Place. For inspiration. information. and a community. community. of like-minded. Professionals. Let's get to the show. Hello? Hello. Thanks for being here. I cannot believe November is in full swing. I am continuing to work on the upcoming lean out confidence course. And I'm going to be getting a few more interview episodes out for you before the end of the year, I will take a short break, maybe a couple of weeks at the end of December before starting up the next season, which is season three of this podcast. I realized that in my last episode, when I was talking about perfection and comparison, that my voice was actually fairly hoarse, because I had filmed videos all day before recording. So sorry about that. The other gift I have for you is a special sale on my coaching services. If you've been thinking about one-on-one coaching now is a great time. I'm giving you 20% off a coaching package during this month and next month that's November and December, 2024. Go to practice balance.com and sign up for a discovery call. My guest today is a fellow physician, coach, and friend. Dr. Kara pepper. Is a practicing primary care internist and executive coach in Atlanta, Georgia. After 14 years in private practice, she built her own 18 state telemedicine practice for adults across the Southeast. Focusing on patients with eating disorders. Kara is also the founder of micro-practice mastermind, a community for physicians transforming healthcare through solo practice. In addition to all this carrot is the host of the podcast. It's not just, you. Which I've had the privilege of being on and we'll link my episode in the show notes. Kara was one of the first guests on my podcast and she's also one of the women profiled in my book. Lean out. Her practice has evolved since our last conversation. And so has her coaching focus. So I thought it'd be fun to have her back on the show. Without further ado. Here is my conversation with Kara.

KP-Dawn

Cara Pepper, welcome to the lean out podcast again. I'm so happy to have you here.

KP-Kara

I'm so glad to be with you as always. Great to see you.

KP-Dawn

Yeah, you too. So this is your second appearance on the show we've known each other for a number of years. And as I mentioned in the introduction, you also, were profiled in my book, Lean Out. And for people who don't know and aren't familiar with you, can you tell us a little bit about yourself?

KP-Kara

Yeah, I am a creative, curious person who highly values autonomy. I was a professional ballet dancer before I was in medicine and, um, due to some eating disorder related injuries. Couldn't dance anymore. So brought all my perfectionism and workaholism with me into medicine and built a career where, you know, I really thought exactness and overworking was the way to success. In many ways it is, I think, um, certainly culturally supportive in our, in our, profession, but, Anyway, I basically worked myself into the ground, looked great on paper, and seven years into practice couldn't get out of bed anymore. I was so profoundly burned out and so ashamed of that because I thought everyone had their act together. So I took a sabbatical of only six weeks because that's maternity leave and God forbid I actually take more time for myself. And in that window of time I had a lot of people start coming to me, like, they thought I had the answers because I was brave enough to actually say, you Pause I can't do this anymore. So I returned to that practice worked through the pandemic and really came to terms with my own mortality. The fact that I could die by showing up at work every day was a new concept. And I decided I would regret spending my 40s the way I was spending it. And so I did. Took a step away from my practice that was wildly successful, built my own solo medicine practice. It's grown to 18 states for telemedicine and now has an in person arm and I do mostly eating disorder care, along with helping physicians figure out how to build their own solo practices. That's the short story.

KP-Dawn

That was a really good synopsis, actually. Last time we talked on the podcast, you had stepped away from this traditional practice. And to start a telemedicine micro practice, but there was no in person arm. Tell me why you decided to add that back.

KP-Kara

Yeah. So I, I was writing out my non compete. Frankly, I'd built the telemedicine, arm of my big hospital owned practice, liked telemedicine and thought this is a great way to still practice medicine on my own terms, but do it from home and be able to recover from burnout. And honestly, I wasn't really excited about going back in person because telemedicine was really serving me. I can practice anywhere I wanted to practice. Yeah. I know as an internist, my brain is my most important clinical tool. And so I really felt like I was providing great value, but I underestimated how important it was for patients to have hands on care. There is definitely energy being in the same physical space, as patients. And so it was a natural organic growth of my practice. Patients wanted it and I could provide it and so I decided to do it. And everyone kept asking me, are you excited about going back in person? And I was like, not really. I mean, I just feels, um, living in service of my patients and it felt okay. And now I'm really grateful I did it and I love it. So I'm glad I'm back.

KP-Dawn

So how much of your practice would you say is telemedicine? What portion is in person? Are there specific days or how do you navigate that schedule?

KP-Kara

So I, am renting a one room office in a house that's owned by a chiropractor and pelvic floor physical therapist. And it's four minutes from my house. And so I drive there and I work there from nine to four every day. And whoever shows up on my schedule, whether it's telemedicine or in person, I'm in the office. So my patients will see me from my office, whether they're on a zoom screen or whether they're right there in the room with me. So I just let it kind of be dictated by the patients. And on a day like today, you and I are meeting on a Wednesday afternoon. I happened to only have virtual patients, so I just came home because I could, and that was nice. Um, but I just let the patients kind of determine what they need.

KP-Dawn

That makes a lot of sense. So now that you have done work that is remote, but in a coworking space or in an office space and in your home, what would you say are the advantages or disadvantages of each one? What's your experience working in those two environments?

KP-Kara

I am an introvert, and I did not realize how exhausted I was working in a space with lots of other physicians. I loved my colleagues, in my previous practice, but even just like the constant conversations in between patients and at lunch and sharing an office and all of that, I just didn't realize how depleting that was for me. So being home in my basement with my dog is like my happy place because I really don't feel exhausted at the end of my workdays because I'm just doing the work and I can be done. In addition to the fact that of course, you know, I can walk my dog at lunchtime and, you know, Go throw in a load of laundry. Like for me, it feels really good, but I do think there's something nice about being able to see patients in person and being in an office. It represents you in a different way. I like having the option for that. And also my brain space, I think is probably a little bit more focused if I'm really honest about it when I'm at work, because all I can do is just work. So I just get the work done a little bit more efficiently. So there's advantages to both.

KP-Dawn

I'm sure that people who are considering making a change like this in clinical practice or even other kind of professions have that same worry or the concerns about, will I enjoy working at home? Will I be too distracted or, you know, will I need to have an office space and how will I find an office space and all those things. And I know you've had a lot of questions from other physicians about this. tell me about. How you have now shaped that into something related to the coaching side of what you do.

KP-Kara

Yeah. So when I became a coach back in 2019, it really was a product of my own burnout. I recognized I'd been struggling and no one was talking about it. People were coming to me for advice around burnout. I particularly specialized in this kind of high achieving perfectionist who is exhausted and overworking personality. And so that's where my coaching got its origins. But with that, yeah. evolved into people really finding their voice and aligning what, what matters. And of course, through my own personal journey of creating my own practice, a lot of those same people kept coming to me and saying, Hey, can I just talk, you know, Hey, can I just get 30 minutes of your time? Can you tell me how you set up your practice? And after two years of that, it really dawned on me that there's a growing number of physicians who want to practice in a different way. They want the patient to be at the center of the decision. They want insurance out of the puzzle or in a different role in their care. And so people are looking for novel ways to practice medicine and really enjoy it again. And so. I do think that healing happens in community. So to bring all those people back together and say, hey, we're all trying to figure this out. This may feel against the grain, but it actually is the future of medicine because we know that our current system is not working well. To bring those people together and bring the resources that I had to dig up by scratch and say, here, here's a roadmap for you, um, has been really powerful and really awesome to help people get back to patient care, which I think so many of us deeply desire.

KP-Dawn

What do you love about this practice model and the new way that you're living life?

KP-Kara

So much. I mean, I would say just on a personal level, the ability to not be the cost of the work that I deeply care about is profound. The fact that I can enjoy making a difference in this world and Then come back to the stuff that makes me, me work is my job. I love it, but it is my job, but the people and the community and the, you know, pickleball and the hiking trips and all the things that I really love doing. There's space for that for so long. I felt like I was cramming my life into the nooks and crannies around work. And now work is the thing that really facilitates my life and I have space for that. So that part is great. I think it really kind of defines the lean out of the culture of, Hey, work is the most important thing that gives you value. But when I think about my why, like I mentioned, I do mostly eating disorder care. My patients are brilliant. I mean, truly, if I can help them be well, the ripple effect that they have in this world and all different walks of life and all different career specialties, like they can literally change the world, but 90 percent of their brain space is taken up by food, body and exercise. And if we can give them some relief, like they will literally change the world. And I feel the same way about my physician coaching clients. I can help one patient at a time, but if I help one physician, that's thousands of patients that they're going to impact. So I really do look at it as these tiny efforts making this ripple that I could never make myself one on one. So it feels really, really important and sustainable, which is a beautiful way to practice work.

KP-Dawn

How do you get patients? Do you have any sort of advertising or do you, is it referral how do you attract people to your practice?

KP-Kara

Yeah. So eating disorder care is a multidisciplinary care. I work very closely with the therapy team and the dietetics team, and so nearly 100 percent of my referrals come from the therapy and dietician world. Of course, there's not a lot of people who do what I do, even though eating disorders are so, so common. It's like 10 percent of the adult population. There's unfortunately no one else in the city of Atlanta who takes care of adults who does what I do. So it's me or no one, which, um, Frankly, is a good business model. And I wish there were more of us cause there's a infinite need for these services right now. In the beginning, as I transitioned from my old practice and built this new one, I was not sure I wanted to practice medicine anymore. I was so burned out and I really felt like maybe I'd done enough. And so I had the luxury of time that I didn't before. I started seeing patients two hours a day just to kind of test the waters again. And because I had all this other free space in my day, I spent it just getting to know the community. So I made coffee dates and showed up at people's offices and went to dinners that were offered. And it was a great way to build these personal relationships that now have really blossomed over the past two and a half years where people, I am the person who takes care of their patients for them. So it's been. It started out as a way to really heal me, but it really was a great business move in that way.

KP-Dawn

Sounds like you're deriving a lot of purpose from this practice, and it's very fulfilling, and I'm so happy to hear that, just knowing you for so many years and watching your journey. Are there any particular trade offs that you can point out to having this kind of a practice, in comparison to what you used to do? Even if it's just perception.

KP-Kara

Yeah, a couple. One is that you get to choose your heart. So, so many people are just kind of used to the system that we're, that we work in. And I think this is true for any industry, not just healthcare, where you just like, know the pitfalls and it's what you've kind of figured out your own workarounds and your own mindset shifts. And the thought of building something from scratch can be really overwhelming. So often people will say, I'd rather just stay in the misery I know than deal with the uncertainty of something that's new. Because that just feels too scary. And we know that imposter syndrome is predictable to show up in those transitions. Like, Oh my gosh, I'm doing it wrong. What are people going to think? I don't have the skills. All I know how to do is practice medicine. There's a lot that people say about that. But anyway, It, it really was a chance to, to create something new. And so, choosing your heart I think is part of it. I don't think that I'm particularly special in that way. I just knew that I couldn't keep doing it and I was willing to make that choice. I'd kind of gotten over that inertia. Um, and then the other part, I'll just be candid about my business model, I don't take insurance, and when I was looking at how I could make that accessible from a patient standpoint, we all know that healthcare is crazy expensive, even if you have insurance, the cash pay models that exist, one is concierge medicine, where people pay a retainer, And the physicians bill insurance. So they double dip. And that didn't feel right to me. I didn't want people to have to pay a retainer to see me. There's the direct primary care model, which is a low cost, but monthly subscription model. And I didn't want people to have that sense of obligation. I wanted them to have autonomy. I mentioned that was in my core values. And so this pay as you go model is actually pretty nontraditional. in our medical society, but it's the way medicine always was. You showed up at the doctor, you paid them with chickens or eggs or cash, and you went about your day. So often when people are confused by that, I'll say, well, you know how you go to the grocery store and you pay them money and then you take the groceries home? It's the same. You know how you order things online, you pay the money and they mail them to your house? You know how you like pay a retainer to an attorney and then they give you legal services? It's the same. It's like seeing a therapist. You just pay as you go. And so. Understandably, some people don't want to pay cash. That feels icky to them, and they want their insurance rightfully to do what it's meant to do. It just doesn't. And so it's been a little bit of, um, an educational opportunity to show folks how much money they're really spending on what they're doing. They should be receiving for free, theoretically, and that it's actually cheaper to see me because working outside the insurance networks, I can get labs 90 percent off, I can get imaging at deeply discounted prices, and seeing me, you see me for an hour, and I'm on time. I don't run late for my appointments. So, if you want quality care from someone who knows what they're doing, and you want time to have your questions answered. It actually is much more cost effective than seeing someone through your insurance and then bouncing around amongst multiple specialists who are not going to coordinate your care. So the short answer to your, is there a pitfall? It does require showing people the value in what you can offer. And in medicine, we're taught not to be sleazy and salespeople, but I think showing people the value you offer is an acquired skill. And so that's something that people can consider if they're considering stepping out on their own.

KP-Dawn

So is this type of learning part of what you teach when you have your masterclass for other physicians on micro practices?

KP-Kara

Yeah, so there's the pragmatic stuff, like, here is the paperwork you need to start up a practice, here are the legal considerations, here's how to hire a virtual assistant, there's like the normal things that I had to figure out on my own that I will, that I just lay out for people. Here, here is literally the step by step process to build a practice. And there's crowdsourcing, of course, because if other people are doing it, they may have much better ideas than I do, so that part has been fun for me to grow my own practice and learn things. But I think the coaching part really gets to the mindset. I think we have this kind of resistance, like I'm thinking about leaving. Okay. I'm ready to leave, but this feels scary. Okay, great. I'm going to leave. And then there's this like big chasm in the middle. I call it the messy middle where you're like, what did I just do? And that is real fear. It's like, you're on a boat that's far from the shore, but you're not quite at the horizon yet. It, it could feel really scary. And it, it really does take a lot of support and community and reassurance. And so that's. Expected. We know that's going to happen. So that's the coaching part that, um, really addressing what's coming up for you is this money scarcity is this imposter syndrome do you just need more data and financial planning? So, so it really reaches the tactical part and the mindset part, which is why we do it in groups.

KP-Dawn

Sounds great.

KP-Kara

Thanks. It's.

KP-Dawn

mentioned earlier Pickleball and hiking. And last time that we talked on the podcast, you were talking about branching out into doing a little more travel that you had been putting off with your husband and such. And I'm wondering nowadays what you're doing with your off time. Tell us about your adventures. You had some photos on your social media about going to far off places to do some hikes and things like that. Yeah.

KP-Kara

your, your listeners who can't see this, this is my emotional sport water bottle. It's got all of our national parks on it. There's 63 in case you haven't been counting. And so every time I go to one, I get a little sticker that I put on there. And so, you know, I've always had these like big dreams of like wanting to be overseas and live overseas and go see the, you amazing, wonderful things that are in this world. And I still do. But I think COVID helped me center back even to the United States as dysfunctional as our country may be from time to time. It's beautiful. There's so many amazing places and I don't have to convince you of that. Cause you're living it right now. I can see it in your background. Um, but I've done a ton of hiking within our country and This year alone, I've been to, you know, Mount Hood, I've been to Mount Rainier, I went to Yellowstone, I went to Glacier National Park. Um, trying to think where else I've been. Those are just like the big kind of land landmark kind of places, but tons of like hiking in the woods in North Georgia and other places. And so it's been really, really spectacular to have that grounded awestruck feeling. It really does like light my soul up in, in many ways. So I'm working on getting all the stickers on the water bottle. That's next year. We're headed up to New England and we're going to do Maine. So it'll be fun.

KP-Dawn

Ooh, that sounds awesome. Um, yeah, I think that being outside is something that I love doing is therapeutic for me and that I recommend to friends and colleagues and clients because it gives you that sense of awe, which gives you a sense that your problems are but a mere speck in the world. And so you get that perspective and the beauty and that mindfulness aspect of it. So I, I love that you're doing that. And then at the same time, you're moving your body. And I know that you love to be active. You're very into yoga and exercise and all of those things. So it, hits all of those boxes.

KP-Kara

Yeah, it really is that when we look at like the data behind stress recovery, um, the stress cycle, you know, it's a lot of those things that you just mentioned. It's being in community, it's being outdoors, it's being, active, and I think that's the big piece of self compassion that's probably taken the longest for me to really internalize. You know, I was a professional athlete before I was a physician. I danced and then I was a marathon runner and then I was, you know, rock climber. I've done all these kind of like big, heavy, intense things and I really was leveled by our pandemic, not just professionally and emotionally, but my body was like craving some gentleness for the first time, perhaps, and, um, hiking, hiking. That's my son says, mom, it's just walking in the woods. It's no big deal. I mean, yes, it could be really hard, but in essence he's right. Like it is a very compassionate way to move my body in a sustainable way, especially as I age. Just let me have the beauty and the awe and the, the stress recovery without, being the price of that I don't have to beat my body up anymore to really enjoy what all the amazing things I can still do.

KP-Dawn

Hmm. Wonderful. Well, Cara, do you have any advice for a physician or any type of professional for that matter, because it doesn't apply to just physicians, who wants to branch out and go out on their own and do a micro practice, go away from the traditional models?

KP-Kara

Yeah, I think the first step is to one, just understand what you personally need. There are plenty of people who are worker bees who love just doing the thing. They don't want to have to be a leader. They don't want to have to make the decisions. They will do great work and make an impact in that way. And that is, Great. But for people like me who want to learn and grow, who are looking at the systems being like, I could do this better. I know I could do this better. I know there's a better way. It's okay to get curious about that. And that's okay. when we come up through our training, we're often given this idea that you can either stay in academics or go into private practice. And I think in many, areas, law is the one that comes to mind frequently, but not only, but there's this kind of like set idea about how you're supposed to do things. But we used to leech people for a living. We thought that leeching people was like a great way to practice medicine. And we decided maybe that's not, the best. And so I think that's how you can look at your career. It's. That the desire to leave and try something different is not failure, it's a sign of growth and evolution, and so giving yourself permission to just imagine that, and if it feels scary, that probably means you're being pretty realistic about it, like, yeah, it's not easy, but you get to choose your heart, and there may be a season in life where you're drowning in small children and things like that. So, yeah. Trying to get student loans paid off that it feels too big of a thing to take on, but it doesn't mean that you'll never be ready. And my hospital employee job was the right job for me at 30. It wasn't at 45 and that was the right time for me to take that step. So it's not a never, you can put a window where there's a door. Sometimes you can put a door where there's a brick wall. Sometimes there's always like a little gap that you can keep open. And so just giving yourself permission to imagine what's possible is that. And then I think the second part is that you don't have to do it alone, no matter what you're doing. There is someone who's done some version of this, and they may not be in your immediate vicinity. You may need to reach out to a group outside of your city. You may need to reach out to a group outside of your industry, https: otter. ai I mean, Chick fil A is here in Atlanta, and people often look at them in their hospitality model and how do you develop teams and how do you develop service, but in healthcare, I can look to them as a model. So you may just have to go outside of your industry. So someone is doing this and you can gain information. And I would bet on your listeners a hundred percent of the time. They're amazing humans. And I, I think that no matter what they decide they could do, it's just a matter of giving themselves permission.

KP-Dawn

Oh, that's such good advice. Is there anything else that I haven't asked you about that you want to talk about?

KP-Kara

I just love what you are doing. I think this piece of permission to say it's okay to do life differently. You are probably familiar with this article by that Australian hospice nurse, Bronnie Ware. You and I may have talked about this over time, the top five regrets of the dying. For your listeners who don't know, it's an Australian hospice nurse who, Interviewed people on their deathbeds and said, what do you regret about your life? And she came up with a list and then published an article. And the number one regret was that I wish I didn't live for other people's expectations. And then the second one was that I wish I didn't work so much. And I don't even ever remember the other three, but if we can just get those two right, like, if you don't know what to do, ask the you on your deathbed. And if that person's like, this, what you're doing right now, it may look great on paper, but this is not it. You would regret this life. That is plenty of information. Future you can give you permission and perspective. And so I always try to keep the me Um, hopefully many, many years from now on my deathbed, in mind when I make these decisions. And I think she would be pretty proud that I did the really big, hard, scary things of stepping away and just creating a life that doesn't look like anyone else's, but it's the right life for me. And that feels really important for your listeners.

KP-Dawn

absolutely. And it's an important reminder for me. I have just loved watching your evolution and have seen the great things that you've been doing and, you know, internally and externally, really. It's a pleasure to know you. I'm so glad that you came back on the podcast.

KP-Kara

Thanks for having me. It's really good to see you.

KP-Dawn

Yeah, you too. Tell us where we can find you if we want to learn more about your work or contact you.

KP-Kara

Yeah, absolutely. If you can remember my name, you can find me. It's Kara with a K, K A R A, Pepper. Md. Cara Pepper Md. That's my handle on all socials and it's my website carapeppermd. com. You're welcome to reach out to me any time. I'd love to hear how your listeners are doing and how this resonated with them.

KP-Dawn

Thanks again so much.

I love talking with Kara. It's always both enjoyable and illuminating. I'll be sure to link our previous conversation along with my appearance on her podcast, in the show notes. Here are my takeaways from this conversation. Number one, leaning out is a process. I was reminded of this by hearing carers updates to what she's been doing. Kara started her lean out journey with a mini sabbatical. She experienced coaching and added that to her work-life balance. Then she transitioned to her own telemedicine practice, which she has now expanded to multiple states and has an in-person component. She's changed her coaching focus from perfectionism to assisting others with starting a micro-practice. You start by starting and you pivot along the way as needed. Number two. You need activities in your life that complete the stress cycle. The stress cycle from a primitive standpoint is where a threat occurs and you are activated in your brain. You make a move then to close the cycle such as you see a lion far off in the Savannah. It turns your direction. You get scared. And so you run away. So you're completing the cycle by doing the physical movement of running away. There's an interesting book on this subject by the Nagorski sisters called burnout, the secret to unlocking the stress cycle. And I will link that in the show notes. Examples of ways to complete the stress cycle in modern times include physical activity like running, but not necessarily running away from a lion. Having a hug. Sleep. Laughter. Taking a moment to have a good cry. Or going to a community social gathering. Kara's activities that she's focusing on now are hiking and pickleball, which give her all physical movement and community. And these help her to close her stress cycle. Number three. Choose your hard. This has two meanings to me. The first is that everything we choose has trade-offs there is no perfect job or perfect work life balance. There are always downsides to everything. Kara talked about the flexibility in her schedule, but also the downside of uncertainty and learning some business aspects from scratch. But the second part. Of how I interpret. Choose your hard is that you get to choose. You don't have to let others choose for you. My parting question to you today is what shift do you need to make in your thinking to view, leaning out as a journey rather than an outcome?