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.
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