Sarah Marino, MD - DPC Internal Medicine in Austin, Texas

Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision, and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There's no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor.

Eva Sheie (00:28):
Thanks for listening to Meet the Doctor. My guest today is Sarah Marino. She's a board certified internal medicine doctor, and she's also a direct primary care doc here in Dripping Springs, Texas. Nice to meet you, Dr. Marino.

Dr. Marino (00:42):
Yes, thank you. Nice to meet you.

Eva Sheie (00:47):
You might be the closest geographically to ever to be on the show of all, but I think you're 160, so you hold the record for being right down the street from me.

Dr. Marino (01:00):
That's small world. That's awesome. Lovely. That's an honor. Yep. We're about 10 minutes apart. That's cool.

Eva Sheie (01:06):
How long have you been doing Direct Primary care?

Dr. Marino (01:10):
I have been doing this about two and a half years. I made the switch whenever I was pregnant with my second baby, so actually I guess that's three years I've been doing DPC. It was a slow start and I kind of phased out of hospital medicine in the process. It can be hard to start your own business and titrate one thing on while you're titrating off the other, but I eventually got to where I was doing this full time all throughout the week and initially started in town in Austin, but then when our family moved out here to Dripping Springs a few years ago, I moved my practice to Dripping Springs.

Eva Sheie (01:51):
I've never heard anyone talk about titrating their life, but I like it. I'm going to keep it. I would like to titrate away from work a little.

Dr. Marino (02:03):
Yes, exactly. Well, you're welcome.

Eva Sheie (02:07):
Okay, so was it scary going out on your own? You like was ever going to come see me over here all by myself?

Dr. Marino (02:16):
Exactly. It is scary to start your own business with zero patients. It is. So that's why I said I kept doing hospital medicine with my old group doing perioperative medicine here and there, and I would just see patients in between during the week whenever I had time. Eventually though, it got to the point where I had to do this dedicate full time just because of our model of guaranteeing next day availability to our patients and needing to be available for communication and things like that. And I'm very fortunate to have a husband, a partner who is also working. So I think for a primary breadwinner, something like this would be even harder. So I'm very blessed to have that and to have that cushion during the transition. But yeah, it is scary to go out on your own. I had some mentors that helped talk me through some of the business items and the logistics of it, but eventually you just say, I think I have enough to get started and I have a good product and I am very passionate about it, and so here we go. So that's what I did.

Eva Sheie (03:28):
Were there services you knew from the start that you absolutely wanted to provide to people?

Dr. Marino (03:37):
Yes. Well, the core of Direct Primary Care is more time and more availability, the direct nature of their relationship. So I knew that at the bare minimum, if I was going to have this model where you ask people for sort of a membership retainer I guess you could call it, which is in my view and how I share it with people is it's kind of a form of insurance, but in my opinion, a form of insurance that just makes more sense. You know exactly what you're getting. There's a menu of items that you're getting for a monthly price tag that is wildly cheaper than traditional health insurance. And so I just wanted to be able to offer people exactly what it is, direct primary care. So I guarantee next day availability for any urgent needs or sick visits, direct communication with my patients via a patient protected or HIPAA compliant application, just like texting on WhatsApp or anything else. Deeply discounted labs at wholesale costs. That was something I was really, really passionate about and took a while to iron out because one of the annoyances of traditional medicine these days is no transparency and cost and prices and constantly getting bills in the mail for something that you did 3, 4, 6 months ago, surprise bills. And so I've negotiated,

Eva Sheie (05:04):
I thought you're going to say 3, 4, 6 years ago.

Dr. Marino (05:08):
Months ago. I think that's against the, I think the years is against the law now, but I have negotiated down to a wholesale cost with a lab that, and I do pay for those labs myself, I build into my account. And there's a trust factor there with patients because I do reimburse myself for those labs. But wholesale costs of labs I think is a huge service because I can guarantee that if you're seen in my office, you'll never get a lab bill in the mail. And that's a big deal for folks. And so I'm also saving them a lot of money and all of the third parties in medicine and all of the inflation and the lack of transparency was something that as a patient myself was really frustrating and just maddening. And so from a business standpoint, that was something that I wanted to offer, be able to offer my patients. I do offer some minor urgent care things as well, like most acute care, primary care doctors, flu testing, COVID, strep throat swabs, the stuff that you see at the traditional doctor to save my patients urgent care visits, minor skin procedures, EKGs. In a lot of ways it is a typical doctor's office, just the business model is different

Eva Sheie (06:28):
When people switch over to you from what they used to do, which I think many of us have a lot of trauma around. What kinds of things do they say to you? Is there something you hear over and over from people?

Dr. Marino (06:45):
I think the number one thing is at the end of a visit, Wow! Thank you for your time. I spend an hour with people the first time we meet for a yearly physical that includes lab review, EKG, and just getting to know people. I mean, that's one of my favorite things about this model is that I get to know about their lives and what they do and their family and where they went to college and where they're from. And so I just love getting to have time to talk to people. In the old days, doctors knew whole families. And all of that information is really important for making me a good consultant and being able to speak into somebody's life concerning their health. So it's never about one thing when it comes to healthcare issues, never. It's almost never about one thing. But if I only get seven minutes with a stranger who has a slew of medical issues, then I'm really handicapped when it comes to effectively helping them. So I kind of turned the question a bit, but I think patients, as much as I appreciate that time, patients are really surprised at how much time I have to just sit with them and they're really, really appreciative. And even outside the yearly physical exam, all of my appointments are 30 minutes.

Eva Sheie (08:06):
Amazing.

Dr. Marino (08:08):
It is a luxury of, it is a luxury of DPC. Yes.

Eva Sheie (08:12):
I've been a believer for a long time, and I can remember getting to the point where I would go have to make an appointment and explain what was happening to multiple people and then beg for an appointment and then see a mid-level. And I remember getting to the point where I thought to myself, I haven't seen my actual doctor in years. And all they would do is it was like you'd say something and she'd go, okay, and write you a script for that. And then you'd say the next thing and she'd write you a script for that. And I would be like, are we going to figure out why this is happening?

Dr. Marino (08:50):
Yeah. I hate that. I'm sorry. And I always try to be careful to not speak negatively about my colleagues. I do feel for some of them, and some of them do feel very stuck.

Eva Sheie (09:01):
Oh, they all want to be doing what you're doing now too. They don't like it either.

Dr. Marino (09:06):
Yeah, it's hard for them as well. And there's a lot of physician burnout and not everybody, like I said, the luxury of DPC. So hopefully what I'm doing is even more mainstream one day. But there's a lot that goes into being able to do this. But the seven minutes that I quoted while ago that I didn't make that up, that is a statistic for internists in these zip codes to be able to meet their income goals and to live the way that a doctor would want to live in a community like this. They really only have seven minutes to spend with people, which comes out to be between 20 and 30 patients a day. So it is hard. And for those that feel stuck and want to get out, I do empathize with them.

Eva Sheie (09:50):
Does seven minutes include charting?

Dr. Marino (09:53):
Yes.

Eva Sheie (09:55):
So you're talking and typing for seven minutes.

Dr. Marino (09:58):
Seven minutes to spend face time with you. Yeah. Yeah. It's a tough situation, especially for, but hopefully, like I said, more people are doing this very soon and it's not super new. I'm not a harbinger in the field. I mean, I have colleagues whose practices are full, so they're doing a really good job and patients are hearing more about it and seeing how much it makes sense.

Eva Sheie (10:23):
It does, and especially since a lot of people's insurance plans are high deductible, so we're already paying for everything, and it ends up being less expensive to have a DPC membership somewhere than to just navigate the system and pay what you want. And I think for people with important, well, any job for anyone with a job, it's a big deal to try to sort out a health issue. And just getting to the point where you're in front of the doctor is a huge undertaking today.

Dr. Marino (11:00):
And briefly, you mentioned, I think what I do is paired really well with a high deductible health plan. So I understand for ER visits and if you were to get cancer, those plans still make sense because of the healthcare landscape in our country, but if you paid a little bit less just for the high deductible for fire insurance, then you would have extra disposable for direct primary care and other cash pay options.

Eva Sheie (11:34):
The math is getting closer and closer as time goes by. Yeah, I think it's wonderful what you're doing. And especially out here, it's not that Dripping Springs is a small town, but there's still a lot of things that aren't out there. For example, Target is not in Dripping Springs, which is why I don't live out there yet because I cannot be too far away from Target.

Dr. Marino (12:03):
Understood.

Eva Sheie (12:04):
But there's also other things that haven't kept up. As the city has grown, you're also, I think, still in a little bit of an underserved area for healthcare.

Dr. Marino (12:15):
Absolutely. I agree. From a business standpoint, I still like that. I don't have many competitors. I know they're all coming, but there are a couple of clinics. I don't know if they have doctors in the building, but there are a couple of direct options. But towards Austin, I do have some colleagues that are doing the same thing or they have that as part of their menu of options, but there aren't many of us in dripping yet. So we're still trying to grow. I'm still trying to grow while I can.

Eva Sheie (12:50):
Are more of your patients men or women or is it about 50/50?

Dr. Marino (12:55):
I think they do have more women. I think that is probably still a function, not to stereotype them, I'm just talking in broad strokes, but I think women are still more likely to seek out preventive care and holistic want to know the numbers and know the data and the biomarkers and ask for help. I do have several men patients. A lot of them are spouses of the women, but I do, there are more women. I also see some older teenagers. A lot of parents want their kids to start looking into their health sooner, which I love instead of being done with a pediatrician and not going to the doctor until they're 35. So older teenagers and beyond is really my target patient, my target demographic that want primary, holistic, functionally minded care.

Eva Sheie (13:55):
How often do you have to refer people out for other specialists?

Dr. Marino (13:59):
I refer out every week for different things. As an internist, we jokingly kind of call ourselves a jack of all trades and a master of none. So we are trained to know a little bit about every organ system, and we all have our strengths in the things that we are interested in and love. But I mean, last week I made referrals for colonoscopies. I made referrals to ENT. Dermatology. Cardiology is probably most common just because it's very close to primary care, especially in the 40 to 65 age group. If there's elevated cholesterol or hypertension that I haven't been able to fix organically or help, I shouldn't say that, you the patient is who really is in control of fixing the issues. I'm just a consultant, educated consultant, but with diet, exercise, a couple of medications. Sometimes I'll refer to cardiology for help with that investigations like echocardiograms, and if I see something on radiology that is concerning, I'll refer to oncology. So I make, the point is I make referrals out every week.

Eva Sheie (15:13):
You have memberships that are for couples and for families too. Can you actually take care of everybody in the family?

Dr. Marino (15:21):
I can take care of teenagers and beyond since I am an internist and I'm only trained on adults. So family medicine doctors and peds. Obvious pediatrics obviously is trained in taking care of kids, and I really like to stay in my lane. So I will see teenagers. They're for the most part, they're little adults, but yes,

Eva Sheie (15:46):
Their brains aren't done.

Dr. Marino (15:49):
Yes. Their bodies are when it comes to labs and EKGs and blood pressure, most of my stuff, I see older teenagers as little adults, so I'm fine with that. But yes, the first patient pays the basic membership and then every adult family member after that that lives under the same roof gets a $20 discount. Right now, my pricing is at one 20 a month, and then every next family member is $99 a month for unlimited care.

Eva Sheie (16:24):
Excellent.

Dr. Marino (16:26):
Yeah. Thank you. It's working out well. They think it's reasonable. People have been very respectful of my time. It's a great mutually respectful relationship, and it's worked out really well. I haven't felt patients don't take advantage of that. I think that patients are happy with that price point for what I offer throughout the week.

Eva Sheie (16:53):
Yeah, I can see why. What do you think that people don't know about DPC that they should know? Is there anything that comes to mind?

Dr. Marino (17:03):
I think just getting their minds around that you can have a healthcare relationship with a professional without insurance. That has been, and maybe for older patients, when health insurance was kind of like a badge of security for so many decades. If you didn't have, you were getting a new job. And it's like, well, do you have benefits? I think that for maybe the 40 plus demographic, just getting their minds around, yeah, I don't even need to see your insurance card. It doesn't matter. It doesn't hinder what I do. This relationship, I work for the patient, I work for you. And that is really freeing for me. But also for the patient, the autonomy that this model provides is sometimes people are kind of slow to wrap their head around just because they're undoing decades of thinking that that insurance is healthcare, But it's not.

Eva Sheie (18:04):
Not even a little. Yeah. What does that first visit look like?

Dr. Marino (18:20):
So for the first visit, I like to have labs done before the first visit. And again, that first visit is an hour. I like to have labs so we can have some objective data to go over and make the most of our time. So the first visit includes reviewing, just getting to know each other a little bit, going over the medical history and intake form that I had people fill out as well before they come in. So going over medical history, going over the fresh set of labs, and then any diagnoses that may come up because of those labs. We'll talk about those for a little bit. And I'll do a little bit of education. That's usually about the first 30 or 40 minutes. Then I do a physical exam, which includes an EKG for all my patients, and then all the other pieces of an exam that you would get at a typical doctor's office.

(19:10):
And then we spend the last 10 minutes or so coming up with a plan moving forward, whether that's nutraceuticals, a new diet plan, a new exercise plan, my four cornerstones that I adhere to or that I always circle back to include food slash nutrition, mental health slash spirituality, sleep and exercise slash movement. I like to say movement more these days, not as intimidating as exercise. So those four cornerstones are something that I think are wildly important in that I talk to about all my patients whenever it's relevant, and I think it'll be received well just because I think it's very difficult to heal anything in your life with a pill if those things aren't being addressed. So the plan usually involves something in one or two or three of those realms. And then we talk about follow up. Are we going to recheck labs? What are we going to do if that, depending on what, and everything's a group decision, I'm very open-minded on the spectrum.

(20:17):
I have patients that are very open to old retail pharmaceuticals and aren't that interested in functional medicine and root cause. They just like the business model and they want a doctor they can talk to whenever they want. And we do medicine because I respect patients' autonomy as well. And I think that medicine can be looked at as a common grace that kind of makes this world a livable place for us. But I prefer medications just to be a bridge. But then on the other end of that spectrum, I have patients who will not take any medicines even if they need them. They do not like antibiotics. They will nutraceuticals all the way or nothing at all. And if it can't be fixed with their current diet, exercise, and even if they have some, yeah, yeah, exactly. Even if we have some abnormal biomarkers, that's okay. Well, they're happy and living and that's okay too. So I'm just an educated consultant and I'm just here to partner with people to help as much as I can, as much as they want me to.

Eva Sheie (21:21):
What's your current take on hormone replacement and menopause? Are you helping with that?

Dr. Marino (21:30):
Yes. Yeah, I do do HRT. I'm a big fan of that. The main reason is because of bone protection for women. There was a couple of generations of women that really missed out on that because of some misinformation around the women's health initiative, and I hate that for them. But I do have plenty of women on estrogen and progesterone and even some testosterone. I think a tincture of those things more, I'm going to err on the side of those things being helpful more than, and we're careful. We ask about breast cancer history, we do mammograms, we do thermography, we talk about risk benefit. Again, it's a personal decision, but I overall am a huge fan of HRT, especially for the bone support feature because as we age, if we're going to be living longer because we are tackling things like obesity, heart disease, people don't really smoke anymore. These are all great things. We're learning more about functional medicine and how we should eat and extra, but, so if we're going to live longer now, I want to make sure that we're not falling and breaking a hip and living out those last few years at a nursing home. We need the bone integrity and the muscle support to really support longevity and quality of life.

Eva Sheie (22:49):
And do you also manage weight loss with GLP ones? Is that something that you're helping people with?

Dr. Marino (22:55):
Up to this point? I'm not. I'm a slow adopter of kind of new fad, and I don't think it's a fad anymore, but I'm telling you where my mind has been the past year to 18 months. There have been things that have been a little bit that have made me unsettled about them. Yellow red flags. One of the big things was I wasn't really sure if the amount of weight loss that was going on was, and not just me. This has been a common concern was is it really just fat loss or is it lean mass loss including bone and muscle, which I just mentioned two minutes ago. So it can be these medicines weren't created to be taken forever. People are taking them for months and years on end right now. I just wanted to wait a little, to me, wisdom usually says, wait, and I just wanted to wait and see if any other studies came out of things that I could objectively be worried about, if there were any, if any of those worries were validated. I mean, we do know from the couple of big studies that we have that people are gaining weight when they stop them. And so my concern aside from the loss of lean mass, that it's not just fat loss. We're losing important things too when that weight loss happens, but was kind of the yo-yo effect of fad diets and trend pills and things like that.

(24:28):
So we know from two of the big studies that more than 50% of folks gained back 60 to 70% of their weight 18 months to two years after stopping the medications. And so what that tells me is that we're not doing the lifestyle support and the education around how to keep weight off along with just prescribing medication. So two important things to me are maintain intellectually intellectual consistency and maintain the moral high ground. So I just got finished telling you that I don't want to be a prescription writer. I want to put forth holistic, functional, medicine minded care that is for longevity and quality of life. Well, to me, last year, writing semaglutide prescriptions wasn't consistent with that. Things change and I'm open and I'm teachable, but up to this point, I haven't prescribed a lot of that medicine. So on that note though, I am really excited about peptide therapy when it comes to new technologies and new things that are in the market.

(25:40):
I am really interested in that. It's potentially the next phase. And I mean, we've seen this with the GLP one, so it's not super new to lots of people, but potentially the next phase of that widespread widely accepted pharmaceutical industry and moving away from current retail pharmaceuticals. So it's something I might get into more next year in a more hands-on way. Research has been done. I will admit that, and I'm reading into it now. There's lots going on and lots in the future. So I'm currently reading up on that area myself to make sure that it's something that I can get behind with a good conscience that could potentially really help people.

Eva Sheie (26:24):
Thank you for sharing all of that. I like seeing where your head is on those things and your approach to me seems really practical and conservative and we can get whatever we want pretty much online. And that doesn't mean it's the right thing to do.

Dr. Marino (26:43):
Yeah, you can, and there's lots more to peptide therapy than just weight loss. There's cognition, aging well, fertility help, fertility support. So again, if I want to be intellectually consistent, and so if I'm going to be open to peptide therapy and I think in a lot of the realms it could be really helpful and beneficial. That's kind of been the thing that's opened my mind up to using the GLP ones in a responsible way.

Eva Sheie (27:12):
Where can we find you online or learn more about you?

Dr. Marino (27:15):
Marinomedica.com. Medica does not have an L. Marino Medica, it's Italian for medical.

Eva Sheie (27:23):
Okay. Thank you Dr. Marino. We'll see you soon.

Dr. Marino (27:26):
Of course, thank you.

Eva Sheie (27:30):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at MeettheDoctorpodcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, theaxis.io.