When she first began her career as a family nurse practitioner, Dr. Nancy Dirubbo’s initial goal was not to own her own practice. Now nearly four decades later, she finds herself having owned three successful businesses as an NP entrepreneur, her first of which is now one of the oldest nurse practitioner owned and operated primary care practices in the United States.
A contributing textbook author, speaker at numerous state, national and international conferences, she has also been the recipient of many awards including the AANP’s State Nurse Practitioner of the Year and the Lifetime Achievement for Legislative Leadership in New Hampshire. Dr. Dirubbo’s first hand experiences in starting and operating small businesses are inspiring, to say the least.
1. Tell me a little bit about your nurse practitioner background before opening your own practice?
I graduated in 1978 as an FNP from Northeastern University’s FNP certificate program and moved to New Hampshire for my husband’s job shortly thereafter. Initially I found it very difficult to find my first job as a new graduate but accepted a full time NP position with a surgeon.
2. What made you want to start your own practice?
When the surgeon I worked for wasn’t able to give me fair compensation that matched what other NPs were making, I decided I would need to go out on my own if I wanted have control over my salary. This led me to opening Laconia Women’s Health Center in 1985.
After thirty years of primary care, I found myself at point where running the business side of the practice was taking up a lot more time than I preferred, so I wanted to create a unique practice model that would allow me to be part-time and focus only 20% of my energy on the daily business aspects. It was also important to me as well as to receive direct pay from the patients rather than having to deal with the bureaucracies of health insurance companies in this new practice. Combining my profession with my passion for travel, I got my doctorate and became certified in Travel Health, and in 2008 I founded Travel Health of New Hampshire. I knew it would take some time before it would become self sustaining so for the first seven years, I ran both LWHC and Travel Health simultaneously until I was able to confidently retire from LWHC in 2015.
3. Tell me a little bit about the kinds of patients you see, the services you provide and the pace at Travel Health of New Hampshire?
Patients come into my office from all walks of life; each of whom have a different reason for traveling abroad. Some patients are traveling for business, others may be immigrants visiting their country of origin, are families going on a vacation, students going to study abroad, or church groups going on mission trips. While they are all indeed different, they all come to me for the same reason which is to ensure their safety while traveling to a foreign country.
My goal is to teach the patients I see how to be a traveler and not a tourist, and to prepare them for a safe and healthy experience. A typical appointment lasts forty-five minutes to an hour, during which time we discuss the patient’s health and what their plans our for their trip such as what types of activities they’ll be engaging in. We also go over their current immunization status so that I can make a recommendation for what vaccines they’ll need to have depending upon their destination. In some cases, I’ll administer vaccines in my office and if not, I’ll help coordinate vaccines for patients with their primary care providers if it’s cheaper for them to use their healthcare insurance (which I do not except).
I also discuss and provide detailed information on potential issues they may encounter while abroad such as insect borne diseases, food and water issues, personal safety, environmental safety and the medical treatment options they’ll have in the country they’re visiting. We also go over their travel health insurance needs and where the nearest US Embassy is located, should they need it. In New Hampshire, seasonal items such as insect repellant are not always available for purchase at the local stores; so I often keep these on hand to sell to my patients. I’ll also write prescriptions for common travel related concerns such as preventing malaria, for example.
The pace of my practice varies. Because traveling is generally a seasonal activity, I do tend to see more patients at certain times of the year than others, but I enjoy the seasonal nature because it has allowed me to create a practice model that works for me. For example, because I’m not their primary care provider, I don’t have to take call and I can make my schedule as flexible as I want. Work revolves around my life and not the other way around!
5. What has been the best thing about opening your own practice?
Being my own boss, creating my own practice model and receiving direct pay from my patients are all advantages in my current practice; but the best thing overall are the interactions I get to have with my patients. I love the amount of time that I spend with each. Every patient is unique and it makes my day exciting. It’s different than working in primary care in that it’s not a dreadful encounter wherein I’m providing them with a diagnosis for an illness. In this setting, when patients come for their appointments, they’re excited for their trip and eager for the information I provide them with.
Patient interaction was a very important factor when deciding the type of practice model I wanted for Travel Health. As NPs, our philosophy of practice is based on the art and science of nursing but I believe is something we’re losing in our profession as the healthcare crisis rises. Nurse practitioners are being pushed away from what the true model for advanced practice nursing is and into a more medical model, wherein we’re expected to see twenty to thirty patients per day. I believe this causes us to lose focus on the unique care that we bring to patients as advanced practice nurses. In my practice, I like that I can have control over the type of care that I want to provide.
6. What has been the most challenging part of owning your own practice?
The most challenging part is the time and energy it takes, especially when you’re just starting out. You cannot have the mindset that if you’re a good clinician, the business will just follow you. Instead, you have to be able to put your role as an NP aside and be a business owner first; that means you’re the last one to leave and the last one to be paid. No matter what happens, you’re the decision maker; no one cares about your business the way that you do and the business aspect has to be your priority if you want it to be successful.
7. What has been the most surprising or unexpected thing you’ve encountered as a practice owner?
I was surprised at how much support I received from my patients and how excited they were with the model of care that I was providing. On the other hand, I was very taken aback by the lack of support and encouragement I received from the nursing community when I started my first practice in 1985. I think the reason was because at the time, nurses were brought up to believe that our culture was one of a team player and of collaboration; not one in which you’re a leader, innovator or entrepreneur. Fortunately that mindset has gotten better, especially as the healthcare crisis has grown. Now we’re starting to recognize the unique flavor that NPs bring as healthcare providers.
8. NPs in New Hampshire are not required to practice under the supervision of a licensed physician or have a collaborative agreement. Has this been a challenge for you at times or do you find that it’s made your practice easier?
It has certainly made things easier, especially as I can have control over my practice model. But even though I practice independently, I like to refer to myself as self-employed rather than an independently practicing NP because I still do very much rely on support from other providers, NPs and physicians alike. The care that I provide wouldn’t change if I worked with a collaborating physician or not.
9. What advice can you give to other NPs who would like to own their own practices or start their own businesses?
The best advice I can give is something that was passed down to me when I first started out, which is to have a capital budget; double your expenses and cut in half what you think you’ll make in revenue. When I was first told this, I laughed but six months to a year and half into owning my own practice, I quickly found it to be true and right on the mark.
If you’re considering opening your own practice or business you need to ask yourself some questions first. How good you are with money right now? Who will be your patients and/or target market? What is the need for the nature of your business and is it something that is financially viable? Who is your competition? Can you wait the two to five years it may take for your business to generate income?
Lastly, become as much of an expert in business as you can and be wary of you go to for business advice.
Dr. Dirubbo also owns Beacon Continuing Education, which provides online and live CE programs throughout the US and abroad. The programs include topics from improving your clinical practice to starting your own NP business. She is also Fellow of the American Association of Nurse Practitioners and speaks at the annual AANP conference.
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