By Phillip Eskew, DO, a second-year Family Medicine resident from the Heart of Lancaster Regional Medical Center in Lancaster, Pennsylvania. Dr. Eskew expresses his thoughts on primary care and why residents should consider the DPC approach.
APRIL 18, 2014 – From managing hypertension, controlling diabetes, performing joint injections, to diagnosing acromegaly or managing primary biliary cirrhosis; family medicine offers it all. This diversity of diagnosis, regular diagnostic challenge, and chance to form relationships with my patients was why I have always been interested in primary care. When a colleague advised me to avoid primary care because it was too broad and diagnostically challenging, I told him he was right – and this was exactly why I loved it. Unfortunately this type of primary care practice is not currently experienced by the vast majority of practicing primary care physicians, most of whom have been trapped in a third party straight jacket. If you want to be free to serve your patients, you must be free of all third parties.
As residents we should first acknowledge that our training environment is unfortunately third party oriented, providing little to no experience with direct primary care. Multiple studies indicate that our education suffers due to this system. A 2003 Academic Medicine study demonstrated that residents spend around 35 percent of their time on “service activities of marginal or no educational value” compared to only 15 percent in “teaching and learning activities.1” Absurd levels of third party paperwork requirements have proven that drastic measures must be taken to increase resident educational time, such as reducing average inpatient census per intern from 6.6 to 3.5 patients.2“reduced trainee workload and increased participation of attending physicians was associated with higher trainee satisfaction and increased time for educational activities.3” No wonder residents are constantly exhausted, often doubting their decision to enter medicine entirely.
As a second year family medicine resident, I have watched family physicians fall into a state of apathy and resignation. Their role as diagnosticians – using logic and reason to diagnose and treat illness – has been diminished in favor turning them into glorified case managers and box checkers. Too often their job is to follow the cookbook, clicking boxes to satisfy bean counters; never mind the individualized needs of the patient. Their diagnostic and treatment decisions are often oriented around the whims of Medicaid, Medicare, or Blue Cross coverage decisions. As a Family Medicine resident I commonly see patients with no insurance. Many of these patients delay or avoid seeking care out of cost fears and lack of price transparency. For most laboratory tests or radiologic testing I am afforded little to no price information to guide my patients.
Referrals are often not an option. When I feel the contagious cloud of despair coming on after a long day of pointless bean counting documentation, I take a moment to dream about the direct primary care practice I will soon start and regain my enthusiasm for medicine. There are a few rare occasions where I get to buck the system as a resident, and those have been the most satisfying of my young career.
On one such occasion I had a morbidly obese male patient with difficult to control hypertension follow up in my residency clinic after a recent hospital stay. He reported daytime somnolence, witnessed apneas, difficult to control blood pressure in spite of adherence to three medications, and a family history of obstructive sleep apnea. He was a cash pay patient. The pulmonologists and neurologists in town told him it would cost around $3,000 to get a sleep study performed and then a repeat study would be needed to titrate his mask. Knowing this was out of the question, I
A 2010 New England Journal study found that I called a local home health company to get a cash price for one of their CPAP machines. Since I did not need the electronic monitor that other companies use to track adherence (to justify taking back the machine from the patient) or any other bells and whistles, the CPAP machine could be obtained for only $300! I wrote the order for the incredibly grateful patient, made an estimate at an initial CPAP pressure, and then titrated it slightly to the patients symptoms (as is often done in formal sleep lab settings anyway).
These small victories will be much more frequent when I establish my own direct primary care practice. As a direct primary care physician I will be able to spend the time necessary with my patients to actually treat them as individuals. I will be able to locate low price cash options for labs, medications, and radiologic testing. My patient documentation will be based on what matters to me and the patient, not an unnecessary third party. If more medical trainees had an understanding of the freedom enjoyed by direct primary care physicians, family medicine would rapidly become one of the most competitive residency options.
When I discuss Direct Primary Care with fellow residents many appear interested, but too often they hesitate to give it a shot. “I don’t know enough about it. Why is this not talked about more? It sounds too risky to practice independently rather than as a hospital employee.” These are some of the most common replies I receive. The Direct Primary Care model is not mere theory. There are lots of success stories! Take a look some established practices such as such as Access Healthcare4 comparing Direct Primary Care Practice climates.6Summit just outside our nation’s capitol on June 20-21, 2014.7 again! Spread the word about direct primary care so your colleagues may improve the lives of their patients and enjoy their careers as well!
Attend the Direct Primary Care National Summit
You CAN practice medicine
Philip Eskew, DO, JD, MBA
Family Medicine Resident – PGY2
Heart of Lancaster Regional Medical Center
1 Boex, James R. PhD, MBA; Leahy, Peter J. PhD, Understanding Residents’ Work: Moving Beyond Counting Hours to Assessing Educational Value, Academic Medicine: Sept 2003, Vol 78(9), 939-944.
2 Graham T. McMahon, M.D., M.M.Sc., Joel T. Katz, M.D., Mary E. Thorndike, M.D., Bruce D. Levy, M.D., and Joseph Loscalzo, M.D., Ph.D., Evaluation of a Redesign Initiative in an Internal-Medicine Residency, N Engl J Med, April 8, 2010; 362:1304-1311.
4 Access Healthcare PA, Apex, NC available at http://www.acchealth.com/ (last visited Mar 24, 2014).
5 AtlasMD, Wichita, KS, available at http://atlas.md/wichita/ (last visited Mar 24, 2014).
6 Eskew, P. Direct Primary Care Membership Medicine. West Virginia Medical Journal, 2014; Vol. 110(2): 8-11.
7 Direct Primary Care National Summit. http://www.fmec.net/dpc.htm (last visited Mar 24, 2014).