Seven Virtues of Direct Primary Care

Hello folks,

First, and most importantly, I hope you and your families are all staying healthy and adjusting well to our new pandemic reality. 

I would like to share with you a revealing account I read recently of one person’s experience with our healthcare system.  (Reilly, BM.  Waste, Worry, and the Seven Sins of Medicine.  New England Journal of Medicine 2020; 382; 14: 1295-97.)  The piece referenced a 1949 Lancet article describing, in that author’s opinion, medicine’s 7 sins: stupidity, sloth, love of the rare, bad manners, overspecialization, obscurity, and cruelty.  The following story was used to highlight several of them.  An adult male suffered several “spells” of dizziness over the course of perhaps a couple of weeks.  One of them occurred during a workout at his local gym, and the next day he sought evaluation at an emergency room.  Through that visit, as well as consultation with a variety of specialists, including a cardiologist, various expensive imaging studies and some invasive tests, he accumulated a $74,542 tab of medical charges without any of them definitively identifying the diagnosis. 

The author of the piece also describes how the patient’s niece, who is a young internal medicine physician, confidently told him within a few minutes of hearing his symptoms that he was suffering from benign paroxysmal positional vertigo.  (Note the word “benign” in the name; this condition is not life-threatening, though is very uncomfortable and even potentially temporarily disabling.)  The author’s point is that our healthcare system has put most medical providers into a situation in which avoiding those “7 sins of medicine” is increasingly difficult.  As a result then of sloth (failure on the part of the physician to obtain a thorough history from the patient), love of the rare (ordering imaging studies to “rule out” very uncommon potential causes of the patient’s symptoms), and overspecialization (rapid referral to a specialist who focused and tested extensively on causes within his organ system field, but then was unable to address possibilities involving other organ systems), the patient undergoes an expensive yet fruitless runaround of sorts.  Reilly points out that “Of course, these super-subspecialists’ deep experience is narrow” as well as “our system values specialists for their depth of knowledge but not generalists for their breadth.  The geometry is upside down…”  He later points out that “half the waste in U.S. health care – a trillion dollars a year – reflects profligate administrative complexity and pricing one can only call sinful.”  Perhaps cruelty is the sin he’s referring to in describing the pricing situation.

The points Reilly makes are all, in my opinion, valid.  The reason though that I’ve chosen to summarize this editorial for you is that the example he cites, of a diagnostic process gone awry, happens to be the same diagnosis for which I did my first house call after opening up my direct primary care clinic.  The contrast between the two situations could not be starker: I was able to spend approximately an hour with my patient, who was suffering severe vertigo, evaluating him at his home.  Without any blood tests or imaging studies, my clinical evaluation reassured me he was unlikely to be experiencing an ominous problem, and Terri and I were able to arrange an appointment for him that afternoon with a physical therapist who has the expertise and equipment to provide the treatment he needed.  Within 24 hours he was significantly improved.  His only additional expenses for that episode consisted of the nausea medication I prescribed and the physical therapist’s charge (which I suspect he was happy to pay, given that the PT treatment helped alleviate the problem). 

To be clear, I am not offering you this story to demonstrate how great of a doctor I am, but rather to demonstrate how oppressive and yes, sinful, our prevailing payment system for healthcare has become.  By offloading the insurance company yoke, and transitioning to the direct primary care model, I have found myself able to practice medicine in a manner consistent with what I would want for myself or for my family (smarter, thorough, sensible, polite, with better breadth of knowledge, clearer, and caring) without having to struggle mightily against an insurance system to do so.  The virtues of this type of practice are evident to me daily. 


Come check us out at Fountainhead Family Med, and see how good it can be.  

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