As a mid-career faculty physician in a family medicine residency program, I have taken a keen interest in the ‘big picture’ of what is happening to the way our graduates and colleagues practice in the ‘real world’. I’ve watched our residents as they prepare to graduate, deliberating among the most prevalent practice options presented to them in our region, usually as an employed doctor in a large multi-specialty practice, or in an urgent care setting. In catching up with our graduates a few years into practice, it often becomes clear that they lack the sense of professional fulfillment they had envisioned for themselves as residents. These discussions remind me of my own disillusionment with employed full-time clinical practice in the years following my residency training. Admittedly, my first-hand experience has influenced my deep personal and professional interest over the years in the development of the social movement known as direct primary care (DPC).
For a long time, I have wrestled with the question of how best to present the direct primary care movement within the structure of formal medical education. In my work with family medicine residents, medical students and among faculty colleagues, I have tried to raise awareness of this burgeoning practice philosophy within the walls of academic medicine. What I have learned through this effort is that while the simplicity of DPC has continued to intrigue a growing number of clinicians in practice (as well as medical students and residents), the DPC movement has proliferated largely within the blind spot of many in academics. For many of my fellow academicians, direct primary care remains at best a passing curiosity, and at worst a dangerous threat to the project of constructing the healthcare version of the Tower of Babel– a perfectly engineered vertically-integrated system of care. Within the academic framework, it’s been difficult to reconcile the apparent philosophical differences between direct primary care’s singular focus on personal trust and the primacy of the doctor-patient relationship, and the closed-system collaboration of clinicians, administrators and third-party payers in developing a ‘systems-based’ approach to care. These philosophical differences, coupled with the fact that residency training programs are beholden to their health system sponsors, lead to a politicization of the provision of medical care in a way that is indifferent or even hostile to the promotion of direct primary care.
To my chagrin (and that of other DPC-interested faculty physicians), the apparent incongruence between direct primary care and systems-based academic practice has thwarted attempts in creating an authentic, working model of DPC practice for the instruction of residents, students and faculty. In discussions on the development of such a model practice with faculty and physician leaders at my program and others from around the country, a practical solution to reconcile programs’ mission of academic inquiry with their financial and organizational realities has been elusive and vexing.
As the numbers of clinical physicians entering DPC practice continues to grow, I have concerns that our formal medical education process will allow itself to drift farther from the epicenter of a practice model that is increasingly more attractive to a younger generation of physicians. With an increase in the numbers of our graduates entering DPC practices, the educational culture will appear even more estranged from the realities of American primary care. Without a structured experiential component or faculty with first-hand experience in the practice of direct primary care, our educational institutions’ practice management curricula will appear increasingly irrelevant to learners with an interest in independent practice such as DPC.
How then, to deliver on the idea of a ‘teaching DPC practice’? As I’ve pondered the fork in the road between studying ‘about’ the rising DPC tide and entering its proverbial waters, I have decided that it’s not enough to be a spectator on the sidelines of the DPC movement. In partnership with my wife, also a family physician, we’re opening our own independent DPC practice, Vitral Family Medicine, later this month.
The experience of developing a new DPC practice from scratch is at once invigorating and overwhelming. It has forced me to consider aspects of medical practice that most employed physicians have little knowledge of or use for. It requires humility in acknowledging gaps in practical knowledge about the myriad non-clinical fields that influence what we do as physicians. One becomes a quick-study in areas as diverse as real estate zoning, negotiating a lease, corporate statuses and their tax implications, legal and practice implications of opting out of Medicare, OSHA and CLIA compliance, commercial loan applications, website development and marketing. One re-learns skills usually relegated to others in larger practices (such as phlebotomy and giving intramuscular injections). There is the decision fatigue of examining the hosts of tools and services to support a practice, and the judiciousness of trying to figure out what is really necessary to support one’s vision for the new practice. All of these decisions circle back to the primary question of a DPC practice: ‘How will this (product, protocol, service) enhance my ability to serve my patients?’
My descriptions of my practice’s development to physician colleagues is usually met by one of two very different responses. Most cringe at the thought of expending so much time and energy on these perceived extraneous pursuits, while a smaller number are fascinated to consider the intricacies of constructing an independent practice. As for me, I am thriving on the thrill of seeing our gestating practice come into being. And as I savor the sense of accomplishment of preparing to open the practice’s doors, I am reminded of our third-year residents who are about to graduate. There’s a sense of sorrow when I contemplate the chasm between what we teach our residents about practice management and the practical lessons I am learning as I follow my chosen course. The practical education in establishing a practice dwarfs my previous understanding of the intricacies of practice operations. The difference between what I have learned and what I thought I knew reminds me of the old expression, “It’s not what you don’t know that’s dangerous; it’s what you don’t know that you don’t know.”
The passive neglect of the practicalities of independent private practice within our formal educational process make it clear that our institutions have largely given up on sustaining among today’s learners what is seen as a quaint practice concept. Now more than ever, engagement of active independent practices with medical students and residents is critical in promoting a vision of primary care that honors the noblest, time-honored aspects of our profession. As the DPC movement reclaims the exam room space that once was reserved solely for patients and physicians, is it plausible that the movement could prompt a shift in the medical education process as well?
I am very pleased to be speaking at this year’s Society of Teachers of Family Medicine Conference on Medical Student Education in Phoenix. I will be co-presenting this afternoon (January 29th) with Dr. Sharon McCoy George on the ways in which DPC presents a model for medical students of effective primary care, and on the ways it reframes the outlook for present-day students who are considering a career in family medicine.
I am a faculty physician in a family medicine residency program. Judging by the interest in DPC among our program’s applicants who have interviewed this year, it would seem that medical students are indeed hearing about DPC, and that they like what they hear. To many students and others, the timeless values of caring for the whole person, of seamlessly integrating preventive care and care of chronic conditions, and of sustaining the relationship of a personal physician throughout the life cycle are visibly embodied in direct primary care practice. In our present era, direct primary care has become the new ‘counterculture’ in medicine in much the same way that Dr. Gayle Stephens first described family practice as a social reform movement many decades ago.
In speaking with medical students who profess an interest in direct primary care, it seems that a large majority of them have garnered their knowledge of the model from sources outside the formal medical school curriculum. A few have heard DPC physicians speak about their practices to Family Medicine Interest Groups, others have rotated with a DPC preceptor for an outpatient clinical rotation and have shared their experiences enthusiastically with classmates. The fact that DPC as a model is seldom addressed in the medical school curriculum may be a sign that the model has not gotten the attention of medical school educators. As more students express interest in a career in family medicine as a result of the expansion of direct primary care, I believe it will become even more imperative for medical schools to incorporate the model into their presentation of how effective primary care can be carried out in practice.
As for how best to interweave direct primary care into medical school curricula, I will leave that complex topic for a future post.
The emergence of direct primary care has the characteristics of a social movement, defined as a “purposive and collective attempt of a number of people to change individuals or societal institutions and structures” (Zald and Ash, 1966). Moreover, the DPC movement has thus far succeeded largely because it is based on a guiding set of strongly-held principles from which its founders have not wavered. The concept of direct primary care as a reordering of the incentives and priorities of doctors and patients away from those of third-party payers has attracted a large following among physicians and members of the public who laud it as a positive example of disruptive innovation. The genius of the concept lies in its common-sense simplicity, which stands in stark contrast with the confusing complexity of the larger health care system.
As direct primary care gains in popularity, it runs the risk of succumbing to the same pressures that have affected other growing social movements. Namely, the movement risks relinquishing its founding principles in an attempt to accommodate previously held norms within society. While the siren call of more widespread acceptance and recognition of the movement within the mainstream is attractive, I believe it may represent the first challenge to the integrity of the social movement as we have known it.
The most visible example of such a challenge comes in the form of a bill introduced in the US Senate (S. 1989, also known as the “Primary Care Enhancement Act”). This Bill, which ostensibly works to assert the validity of direct primary care as a payment model that is not classified as insurance, also moves to establish a definition of “qualified direct primary care medical home practice” for the purpose of enrollment of practices in a “Medicare Primary Care Demonstration Project”. In order to qualify for this pilot project, qualified DPC practices must comply with a prescriptive set of operational requirements regarding manner and scope of practice (including such requirements as “availability of ongoing care appointments seven days a week”). The Bill also outlines a series of “performance benchmarks”—the same “quality measures” used to measure Accountable Care Organizations in the Medicare Shared Saving Program—which “qualified DPC medical home practices” are required to report if they are to maintain their inclusion in the Demonstration Project.
The promulgation of this pilot project among direct primary care practices places DPC on the same trajectory as many of the social movements that have gone before. While the inclusion of DPC among the practice types of CMS’ pilot project may seem like a flattering gesture to some at the top of the DPC pyramid, it nonetheless represents the first large-scale move to accommodate to the societal norm of third-party payment for primary care services. The illusory belief that this accommodation is necessary in order to make DPC ‘scalable’ and more widely available undermines the defining characteristic of the movement—the direct financial relationship between doctor and patient.
The topic of DPC’s flirtation with the Medicare pilot project evokes visceral reactions from many in the DPC community. From what I can gather, supporters of S.1989 view it as an exercise in pragmatism that is necessary in order for DPC to grow and move to the next level. Opponents by and large feel betrayed by the acquiescence of the movement to the regulations and requirements of Medicare in return for a larger slice of primary care market share. The discussion about how to negotiate with third-party payers sounds a lot like Yogi Berra’s “déjà vu all over again”.
In my opinion, this is an important time for those in the DPC movement to assert the value of direct primary care with the public by being mindful of the foundational criteria of good primary care, as described by Dr. Barbara Starfield and as conceived by family medicine’s founders, such as Drs. Lynn Carmichael and Gayle Stephens. By definition, effective primary care should be: 1) patients’ point of first contact with the medical system; 2) be longitudinal and person-focused (rather than disease-focused); 3) be comprehensive in nature; and 4) coordinate care with other services when patient needs go beyond its scope.
When practiced as it was originally envisioned, DPC performs exceptionally well in all four of these areas. By reducing barriers between doctors and patients, DPC ensures access to the primary care physician as the ‘go-to’ person for patients’ health concerns. Its avoidance of third-party entanglements (which are often employer-based and thus easily disrupted by changes in employer) make person-focused and longitudinal care the norm in DPC. Regarding scope of care, practices can expand their scope of practice beyond what is customary in insurance-based models, with the intent of maximizing the practice’s value to patients. One element of this value entails partnering with subspecialty physicians and others for care that is not provided in the primary care practice (coordination of care).
It remains to be seen how the DPC movement will react to its own rapid growth and early success. Will the siren’s call to negotiate some of its principles in return for greater mainstream acceptance be too enticing for DPC leaders to resist? Might DPC organizers succeed in bucking the trend of previous social movements and manage to shepherd the movement’s integration into the larger health care system without abandoning its core principles? Or will the growing tensions within the DPC community produce a schism, with the fractionation of the movement into a “purist direct primary care” wing and a “Medicare per-member-per-month” capitation wing? Regardless of which side of the debate over Senate Bill 1989 they find themselves, participants in the DPC movement would do well to bear in mind the four essential qualities of primary care—first-contact, person-focused, comprehensive, and coordinated– and ask themselves how their vision for the future of DPC squares with these defining elements.
By William E. Chavey, MD, MS
Physicists have a joke that nuclear fusion is the energy source of the future — and it always will be. The humor here is owed to the thought that the potential for nuclear fusion will be perpetually unfulfilled. I was never funny enough to be a physicist but the corollary in medicine might be that quality is the next frontier in medicine — and it always will be.
The direct primary care movement began as a model of convenience and service with a theoretical expectation of improved value. Proof of quality (and value) will be requisite for the movement to achieve scale in a competitive marketplace. The challenges that have made quality the perpetual frontier of the future are transcendent and the marketplace will apply the same imperfect approaches to evaluating physician practices and healthcare systems irrespective of the delivery model. For DPC practices to complete against traditional systems and– when market penetrance is sufficient–to compete against each other, they will need to master the current quality paradigm. Preliminary results are positive and I remain optimistic about the DPC model’s potential for delivering high quality care.
The volume-based incentives in a fee-for-service world are clearly mal-aligned; but what is the downside of the convenience-based incentives in DPC? I am concerned that the DPC model itself might have some intrinsic, unique quality challenges. None of the challenges I will propose are insurmountable, but they do need to be addressed.
Imagine a simple but common scenario of a respiratory illness. Will the pressure of convenience incent more unnecessary antibiotics —- owed either to patient expectations or to a physician who cannot assure himself in a virtual visit that the condition is viral and thus prescribes antibiotics out of caution?
I have spent the bulk of my career in academics, in a large department with team-based care. The obvious casualty to such a model is that care becomes impersonal and continuity severed. An unanticipated benefit is the transparency that results from having colleagues see your work. At our institution we have identified several situations in which physicians have been able to maintain insular practices even in our large group setting. The result is an intense physician-patient relationship and patients who refuse to see other providers. In most cases the motives are pure and the care of high quality. However, we have also identified some aberrant practice patterns that escaped detection because of lack of transparency. When coverage is ultimately required such as for a vacation, atypical practice patterns have come to light that were not detected by simply monitoring aggregate quality measures. Most DPC offices are similar to what I have described — small, 24/7 physician access to a single physician, and an intense relationship between physician and patient. Will transparency suffer? In the banking industry, it is commonplace for institutions to mandate a two week vacation so that processes are not hidden. Could such a process be helpful or even necessary for DPC?
I also worry about objectivity. The American Medical Association and a number of other professional organizations have policies and position statements advising physicians to avoid caring for family or friends because of a loss of objectivity. Will the intensity of the relationships in a DPC practice impair objectivity? As an example, in our department we have enacted policies to govern the prescribing of chronic controlled substances. These policies require, among other things, periodic drug testing and a more frequent physical presence in the office for patients to be assessed and to pick up prescriptions. Would such a system violate the spirit of a DPC model?
Many of the quality measurements today are based on billing data. I believe it will be important for DPC systems that do not generate bills based on codes to have some discipline for coding to allow for comparisons in quality with conventional insurance-based practices. Also, some uniform documentation and coding systems for virtual care may need to be developed in order to be able to capture them in quality measurements. Going back to my example of the virtual visit for the respiratory illness, without some method of identifying that visit as being associated with a URI, there is no way that it can be measured. This problem itself is not unique to DPC, but the frequency may be.
The challenges that have made measuring and achieving quality in healthcare so elusive are transcendent and certainly not unique to DPC. There are, however, some unique challenges that may behoove us in the DPC movement to consider.
This past week I had the good fortune of speaking with a few academic physicians who are very interested in incorporating Direct Primary Care experience into their residency programs. These discussions revolved around a few potential barriers that most GME programs would have in common if they were to try and initiate a true DPC residency practice under the control of the residency. Here are a few of the barriers that were identified (as well as a few others):
1. ACGME requirements for outpatient clinic visit numbers. The Family Medicine Review Committee currently mandates that all residents must conduct a minimum of 1650 face-to-face office visits in the longitudinal outpatient setting before graduation. Given that DPC practices are not volume-driven– and often obviate the need for office visits for some common complaints– it may be more challenging for residents in a longitudinal DPC practice to make the ACGME visit requirement.
2. Creation of a culture of continuity in a residency program. Residents are busy people, and rarely are they in one place for very long. Whether it’s hospital call, continuity OB deliveries, or outpatient rotations around town, residents are often hard to track down. Patients in a DPC practice often are drawn to such practices because they offer enhanced accessibility to their own doctor. How can residency practices fulfill this promise of continuity and access for DPC patients and still meet the other demands of residency training?
3. The role of longitudinal faculty physicians. The key to economic viability for most DPC practices is the maintenance of low overhead in the practice’s operation. Many of the efficiencies in DPC are achieved by shedding the overhead associated with third-party payer contracts, including Medicare and Medicaid. Residency-based DPC practices would face the challenge of negotiating the status of supervising faculty physicians within CMS and commercial insurance programs. If the faculty physician severs relationships with third-party payers, this leaves the residency program unable to submit charges for the physician’s services in other areas (inpatient service, conventional residency clinic, etc). However, if the faculty physician maintains third-party contracts, s/he must care for patients insured by those payers according to the terms of the contract. How should programs negotiate this apparent conflict when implementing a DPC practice in their residency?
4. Incongruous culture with the sponsoring institution. Let’s face it, the ethos of Direct Primary Care is not exactly what most health system CEO’s have in mind these days when they think of the direction of their institutions’ primary care practices. Many of the rampant changes in health care today are about forecasting payment structures and aligning incentives to maximize payments from third party payers, which often entails the gathering of large amount of data on the part of doctors and practices. To an ordinary primary care physician on the street, it seems as though we’re caught between two conflicting messages: the nation needs more primary care physicians to deliver on the promise of improved access and reduced costs, and at the same time the hyper-objectification of our work makes it seem harder than ever to remain a respectable board-certified physician. How likely are sponsoring health systems to support the establishment of independent Direct Primary Care practices under the auspices of a residency program in this climate?
While these challenges seem like they’d be common to most, if not all, residency programs, I’m sure there must be circumstances where some of these barriers don’t apply. In our conversations around this topic, we came up with a few responses to these challenges, which I’ll share in my next post.
In the meantime, I’d be very interested in your thoughts on challenges to implementing DPC in a residency program, as well as any solutions to meet these challenges!
I’ve done a lot of thinking about how to introduce Direct Primary Care into medical school and residency education. Until very recently, this conversation has largely consisted of me talking to myself (in the shower, in my car, while mowing the lawn), as there have been few interlocutors on the subject. Fortunately, this is changing rapidly, and I’m coming upon more and more faculty docs who share my enthusiasm for including Direct Primary Care in their conversations with learners.
In my estimation, the growing conversation about DPC in education needs to start by identifying feasible and tangible goals for its inclusion. These goals will depend on the needs and intentions of each educational enterprise, the level of learners it targets, and the resources it has to enact the educational plan. Is the goal merely to familiarize the learner with the concept of DPC in a “field guide” of practice options? Is the intention to provide a deeper understanding of DPC principles, and possibly a DPC experience, for students and residents who are considering entering DPC practice upon graduation? Or are there other curricular objectives for which DPC might serve as a vehicle to teach, even to learners not contemplating DPC practice (such as using DPC principles to teach skill sets not commonly seen in residency practices, such as telemedicine visits, or skills associated with low-overhead practices)? Are there DPC practices in the local community with whom to partner?
The conversation often takes a different turn when we stop to consider the ‘How’ of including DPC in medical education programs. Unfortunately, in many cases this will necessitate facing the political implications of teaching about DPC within training programs whose sponsoring institutions are unfamiliar with the concept, and who may see it as incongruous with their overall financial and organizational structure. I will address thoughts on this thorny topic in more detail in an upcoming post.
As DPC continues to grow among community-practicing clinicians, it will be imperative for medical schools and residency programs to acknowledge DPC in their educational offerings, if for no other reason than to provide an accurate representation of the changing primary care landscape. However, beyond merely representing DPC, the present moment offers an opportunity for forward-looking programs to distinguish themselves by developing a robust and knowledgeable approach to Direct Primary Care that rekindles the imagination of students and residents about the possibilities and joys of primary care practice.
What do you think? Join the conversation!
Yesterday I had the privilege of speaking on DPC and residency curricular development at the Society of Teachers of Family Medicine Spring Conference in Orlando. The conference was well attended by a very engaged audience. It was interesting to me to hear the thoughts and ideas around how to institute teaching of Direct Primary Care within residency training, as that’s precisely the reason for the existence of this site!
One of the greatest challenges in including DPC within residency training thus far has been the lack of experience with DPC among faculty physicians. I am hopeful that this will change as residency programs learn how to embed “academic DPC practices” as part of their training programs. Until then, I believe the most viable option for providing an experiential component for our learners depends on developing partnerships with DPC practices who have interest in teaching.
What are your thoughts on how to incorporate DPC into residency teaching?