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 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?
James Breen is a family physician who blogs at academic dpc.
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