Hello wonderful physician colleagues,
I write this two days after my New Year's “hurrah”- the end of more than five years as a founding member, Vice President and President of the Direct Primary Care Alliance.
It has been a privilege.
Dr. Vance Lassey of Holton Direct Care in Holton, Kansas, assumes the President reins for the next two years. I am very excited about where this organization is headed under his strong leadership. In my near-decade of “DPC”, I have encountered few people more passionate or dedicated to authentic physician autonomy and direct primary care. Dr. Lassey’s leadership is complemented by the pragmatism and diplomacy of Mr. Joe Grundy, our Executive Director, the compassion and vision of DPCA Vice President, Dr. Kissi Blackwell, Treasurer Dr. Amy Walsh’s fastidiousness and focus, Dr. Jack Forbush’s (“Special Ops”) technical expertise and willingness to do difficult things and the incredible get-er-done and problem solving ability of newly-nominated Secretary Dr. Tiffany Leonard. In short, this is a stellar group of stubborn, capable, driven physicians. They are going to do (and have already done) many great things.
I believe I became a leader in the Alliance and within the DPC movement, in general, because I demonstrated that a vision for physician independence and for authentic practice can not only be articulated but can be achieved. I have done this personally and have encouraged and mentored others on their own journey. Many of you have, in turn, paid-it-forward and mentored others. We are each paving the way for a brighter future for primary care and medicine, in general.
Dr. Lassey and Joe and I had a thoughtful final conversation on December 30th, my last weekly call as DPC President. We lamented an angry online post written by a home health nurse who asked, ‘what is the point of primary care anymore?’ (not her exact words, but this was her point). She hears, over and over again from the patients that she sees, that primary care physicians are not willing to see their own patients, that they couldn’t get in, that their doctor wasn’t available, that the next visit was too far out to meet the patient’s immediate need and on and on. (Particularly PCPs who won't see sick patients with covid symptoms.) If you have attempted to coordinate any of your own healthcare or that for a family member, I suspect you, too, understand very well how massive the barriers to care have become. Because of these barriers in insurance-based primary care, patients go to an urgent care, or the ER, or a franchise quick-care in a pharmacy or on a street corner and get their care from one of our colleagues or a nurse or someone entirely untrained within traditional healthcare. I have said this before and will say it again: traditional medicine has the *most* to offer patients. But we do it in the worst service-model possible. As such, patients- the consumers of healthcare- really don’t want or can’t access what we have to offer. The pandemic has shone a bright light on this dysfunction. Cohesive systems, under duress, shine. Incohesive systems, under duress, crumble. I believe it is generous of me to say our healthcare system is crumbling. Better would be to call our system exactly what it is: is a steaming pile of poo. We all keep stepping in it and tracking it throughout our daily lives.
Here’s my challenge to the nurse who lamented that primary care physicians stink, too. It’s a challenge to our employed colleagues, nurses, patients, family and the general public. You can hate the player. Physicians are the place where fingers point- from all directions. Administrators say do more, code more, see more, be more compassionate, more available, answer more messages and make sure it’s all done on time and copiously documented in under 48 hours. Patients say: do more, be more available, code/type less, look at me, be available for me, answer my questions (again and again) and do all of this for me while accepting payment from a third party, on time and in a way that is transparent and within my budget. Third parties, aka insurance companies, say, “tell us that again”, do more paperwork, answer another question, submit another form, make sure this is evidence based, talk to our nurses first and on and on. The fingers all blame the player.
But the problem, in healthcare, really isn’t the player. It’s the game.
And it is the game that is broken. Irrevocably.
Direct primary care changes the game. Today, more than ever, we need as many physician-players on the DPC field as we can possibly recruit. And if not DPC, then independent healthcare. Healthcare that answers directly to the patient. Walking away from the game as it is played is the *only* way to shift healthcare back towards serving patients when and how they need served. Not in three months, not after three urgent care visits and not behind layers of scheduling templates, rotating receptionists and off-site triage. Patient care fundamentally requires caring for patients. And patients, as people, simply aren’t ‘template-able’.
Changing the game changes the player. DPC restores the autonomy and integrity of healthcare delivery. DPC has helped me, personally, to reclaim the joy and restoration of the work of being a physician. Sometimes the job itself still stinks. It’s still hard. People can be difficult. And society really isn’t sure what it thinks of physicians anymore. But there is joy in this work. There is value in this work. It requires pausing, reducing, simplifying and being the one who is most available to do the work. I could not do that on the employed-physician playing field. And I really don’t think anyone can, for long.
Direct primary care is about autonomy. It’s about physicians working for themselves and their patients. It’s about being available when a crisis hits, when questions arise, when visits are needed. It's about being able to combine science, training and creative thinking to solve problems, not answer to algorithms. Being available to help people who I know, who have shared their healthcare story with me is enjoyable. Doing my doctor work for the patients I serve feels good. *That’s* what I signed up for.
In eight years with my own DPC I have found that people don’t need all the things RIGHT NOW. They just need to know that their doctor, their medical team, is in their corner and reasonably available when they need them. In primary care, anything that is truly “right now” is an emergency. (And that is what the ER is for, right?). But the rest? That’s what we do as family physicians and internists. DPC docs are here. You can take care of yourself and take care of your patients. There is not a fixed amount of joy or time or happiness such that if a patient’s needs are met a physician’s needs are not. DPC allows for a physician to create a balance for themselves. To say, “I am going to care for you in this way, on these terms, and I am going to solve problems for you and for me.” And there is so much integrity, and sustainability, in that.
So, to my colleagues: I will defend the soul of our profession to my last breath. Being a doctor means something. Being a doctor means something to our families, our communities, our patients and, most of all, it should mean something to OURSELVES. To the person who put in the time. Made the sacrifices. Gave up relationships and visions of other things. We have chosen to give of ourselves to this profession. We have chosen to be the players in this game of healthcare. And you can wake up in this new year, look yourself in the mirror, remember why you set out on this journey in the first place and reclaim your place at the forefront of the healthcare team. On a field of your own choosing and your own creation.
And for the nurse frustrated that primary care physicians don’t even see their own patients: I have a challenge. Perhaps that doctor wasn’t on the golf course drinking a martini. Perhaps she was lying on the floor with her feet up on her desk sobbing because she just can’t do it anymore. Perhaps she was three hours behind and texting her husband, again, to apologize that she wasn’t going to be home for dinner. Perhaps she was forgetting to pick up her kids because she was double booked even though she put a block-hold on her schedule. All of these “perhapses” and more are real experiences from my employed life where I had NO control over my schedule, my time, my life. Perhaps your healthcare colleague was doing her very best and it still stunk.
And to that nurse: the next time someone comes in with something you think their PCP should have handled, give them this email: email@example.com. Even better, tell your patient’s that they have a choice. They can put their feet, their money, their heart and their time where their complaints are. They can move their primary care needs from the ‘3rd-party-insurance-payor-field’ and walk right into the office of an independent, local small-business owned by a hometown doctor. Send every. Single. One. of those urgent care patients to a DPC physician in your region. You won’t see them in your urgent care again. You can find one of over 1500 clinics here: www.dpcfrontier.com/mapper.
If you want the game to change, stop playing it the same way.
Healthcare has a soul. And we are on the front lines of all it can do. This work can be joyful. It can be restorative. It is, perhaps, the most authentic work a person can do. So make it real. Make it yours.
Julie K Gunther, MD, FAAFP
sparkMD (a DPC clinic), Boise, Idaho
Founding Member, DPC Alliance
Vice President, DPC Alliance 2018-2019
President, DPC Alliance, 2020-2021