The door swings open, and Yassini enters the exam room.
“Hi, Patrick,” Kincaid says, the smile returning to his face.
“Hello, Phil. How are you doing?”
“Well, I’m here,” he says, as if the act of living were the greatest medical feat he’s ever heard of.
In a way, it is. A while back, Kincaid explains, he began experiencing problems with balance and having headaches.
“So, Dr. Yassini said that it’s better to get a scan of your head,” Kincaid recalls. “They checked it out and found this tumor there. I met with the doctor who was going to take care of this, and I asked Dr. Yassini to come down with me. My son was also there, and they told me what the problem was and told me how they’re going to fix it. They’re going to zap it off, they told me — so I had five treatments and it’s gone. It’s gone — the tumor is completely gone. I had a check-up a year afterward, and it’s still gone. I’m going in for another one pretty soon to check it again.”
“We had to coordinate care with a radiation oncologist, a regular oncologist, and a neurologist,” Yassini says. “That’s not an easy feat, staying in contact, and making sure everyone is communicating and understanding everyone. That takes time.”
The breaking point
Until five years ago, Yassini tolerated the typical, grueling medical schedule. Then, one day, in a moment of clarity, he realized he didn’t have to do it.
“I remember exactly what happened,” he says. “It was a month that everyone got paid but me. I was trying to explain to my wife why I didn’t bring home any money that month, and the question she asked was, ‘Do you realize you’re working about 80 hours a week?’ It just hit me at that point. I said to myself, This is ridiculous; I’ve been working for free for a month! The midlevels got paid, the staff got paid, the rental owners got paid, the utilities got paid — everyone got paid but me. I was working 80 hours a week to maintain everyone else’s job.”
As we head down the hall to see another patient, Yassini says that, these days, his usual workload is a handful of patients and a few afternoon home visits a day.
Time and time again
Like Yassini, internal and holistic-medicine specialist Dr. Pamila Brar has given up the hectic pace of the turnstile approach to medicine to embrace the most important ally of any doctor.
“Time is the currency of excellence,” she says, quoting direct-pay pioneer Steven Knope. Brar has taken this adage as her mantra.
“I remember hearing that expression and feeling so frustrated, because that was the one thing I didn’t have in my practice — time.” We are in her office at Scripps Memorial Hospital in La Jolla. “These patients would wait to see me for months, and there were patients of mine who were elderly people, hobbling along in their walkers and going to see their doctor, and I only had 15 minutes [with them]. I felt so terrible that I wasn’t able to sit with them and talk about what was happening in their lives.”
A New Orleans native with elegant Indian features, Brar sits behind her office desk with relaxed confidence. Fixing her gaze on the ceiling, she seems to consider every angle of each question.
“Sometimes, it’s just the listening that helps people,” she says. “When my time is so greatly restricted, that restriction interferes with my ability to be present and to provide the best service for my patients.”
Charging a fee similar to Yassini’s, Brar asks for $2500 for individuals, $4500 for couples. She offers a reduced fee based on a sliding scale for children of patients — from $500 for children ages 15–18, to $2000 for children over 35.
After finishing her residency in 1998, Brar entered what she calls “a more standard, large medical group.” For nine years, she put time in with Scripps Medical Clinic Group of San Diego, averaging 15–30 patients a day. Her appointment book was filled three months in advance, and she often worked from 7:00 a.m. to 7:00 or 8:00 p.m., five days a week. Looking back, while she acknowledges that parts of the experience were “gratifying,” she describes the constant high volume of patients visiting the office as a “treadmill.”
“When my patients needed me, I was fully booked up,” she says. “Often, they would end up in urgent care. It was a very frustrating way to practice.”
In 2007, the group sought to alleviate the high volume in the exam rooms by adopting the concierge model Brar practices today. Two years later, having learned the value of keeping the patient front and center, she opened a solo practice.
Brar went from 3000 patients a year to 300 patients in a short time span. It was a drastic change, but the results were remarkable. For what she’d lost in volume of patients, she more than made up in more reasonable work hours.
“The flip side,” she says, “the difficult side of this sort of practice is that you are on call pretty much 24 hours a day. So, you trade the pace for being available all the time. But it’s much better for me.”
The direct-pay approach allows a doctor to hang out a shingle on his own terms, as Dr. Martin Schulman has done in a tony strip-mall in Encinitas. His 1048 square feet of rented office space consists of two exam rooms, a back office, a restroom, and a reception area. He shows me a room set aside for a high-powered laser to treat tendonitis, bursitis, and any other “itis” that comes down the pike. (A few months after we spoke, Schulman moved his office a mile south to Cardiff. An even more Spartan setup, the new 165-square-foot digs consolidates exam room and office — desk, exam table, and other accoutrements — into a single space.)