Dr. Thomas White runs his Direct Primary Care in Cherryville, North Carolina out of the same renovated movie theatre where he watched his first film at the age of six. He’s now in his sixties, and he has a message to deliver to older physicians who have been worn down by the quantity-over-quality medical model: “If it weren’t for Direct Primary Care, my career would be over.”
When I spoke to him on the phone on Sunday evening, he had just returned from a house call to a patient who could no longer make office visits. “I wouldn’t have been able to do that if I was still working within the hospital system--not at the impossible clip of thirty patients per day.” As he discusses his early experiences working as a family physician, it becomes clear that it was not just the location of his practice that was constrained by the traditional care model. Dr. White speaks about the current state of healthcare with a thoughtful criticism that reveals him to be a veteran of a faulty system.
Running his practice independently, as he had done for the past ten years, became impossible during the mid-1990s. Solo practitioners were left in a lurch, unable to negotiate insurance contracts, outfit their offices with the latest technology, manage employees, and practice medicine at the same time. Dr. White was no exception. He began working within the larger hospital system and continued working as an employee of that system, seven days a week, for nineteen years. Dr. White recalls that their model allotted fewer than seven minutes for each patient visit; as a result, preventative care was reduced to checking a series of boxes on the computer: “Have you had your mammogram, yes or no? Have you had your colonoscopy, yes or no?” The kinds of holistic conversations about lifestyle and diet that Dr. White has with his patients today were viewed as wildly unrealistic and even superfluous in a setting where efficiency and speed were valued over nearly everything else. “You can’t do that in a practice when you’re spending seven minutes with each patient, especially when your eyes are glued to the computer”.
Dr. White remembers the day he realized that the larger hospital system’s values were incompatible with his own. “I received several complaints about patients who expected to be seen on the day they called or expected their medications to be refilled within a few days or expected their referrals to be done quickly. I was told by an administrator that it was a problem and that I was responsible because I had spoiled my patients with timely service. In that moment I realized that our healthcare system has lost sight of patients as the primary focus of healthcare. My traditional practice was being run by those whose objectives were different than my own”.
After nearly twenty seven years in business, he decided to resign and try something entirely new. Now, Dr. White harnesses the flexibility and freedom of the direct primary care model to focus on one objective that is entirely his own: giving his patients the best care possible. “I feel like patients should be spoiled with excellent, timely treatment and access. Why are we in health care if that’s not our goal?”
When he applied to Duke University Medical School in 1975, White was thinking very little about the business of medicine or what style of practice would afford him the most lucrative career. In fact, he envisioned his career as a family physician to be much more like his mother’s, who was a social worker, than his father’s, who worked in business. He wanted to provide some of the five thousand residents of Cherryville with the same level of care that his family physician had given him. “I had the great experience of having a family doctor in the community that treated me from a very young age. I watched him as I grew up, and spent time in his office, getting check-ups and occasionally some stitches. Later, in college, I had the opportunity to spend time in his office, go on house calls with him, and accompany him to the nursing home”. White admits that he wasn’t always so keen on being a doctor. “By the time I was a senior in high school, I really thought that I wanted to a be a basketball coach and a high school biology teacher. I was actually preparing to go to Duke when I got in an accident, and I had to spend almost everyday in the doctor’s office for about three months. That close relationship with my family doctor sort of rekindled my interest in being a physician, so I gave up my dream of being the next big college basketball coach and decided I would come back to practice family medicine in Cherryville”. His experience sharing this plan with the admissions officers as Duke was similar to those of other direct primary care practitioners he has spoken to since then. He laughs as he recounts the story--“They looked at me like I had two heads”. Despite the pleas of his peers and faculty, Dr. White did ultimately return to his hometown of Cherryville to practice following his graduation from Duke at the top of his class--just as he said he would.
That was certainly not the last time that he would follow through on an idea that went a little against the grain. “Many people thought my decision to practice direct primary care was crazy. At times, I did too, but I had a lot support and encouragement from other doctors in the DPC space around the country. There are some remarkably unselfish mentors out there”. In the course of our interview, Dr. White not only expressed deep gratitude for the wisdom of his fellow DPC practitioners, but also offered up some of his own, debunking five of the major pieces of misinformation surrounding our modern medical system in the process.
Dr. White: Medical Mythbuster
Myth #1: The 7.7 minute office visit is a new phenomenon caused by the modernization of the medical profession.
Dr. White cites his childhood physician as his major inspiration for starting his own family practice in Cherryville, but there were some aspects of that kind of old-fashioned general practitioner career that he never wanted to replicate. “The thing that I was not particularly attracted to was the prospect of seeing between fifty and sixty patients per day. Most busy general practitioners--especially in small towns--had limited time with patients by necessity. We think that is somewhat of a modern day phenomenon--that doctors used to have plenty of time with patients and then EHR came along and then suddenly we didn’t--when, in fact, in many small communities like mine, family physicians worked hard to see enormous numbers of patients per day”. While Dr. White admires the work ethic of the general practioners of yesteryear, he believes that the 7.7 minute office visit didn’t lend itself towards holistic care then, and certainly doesn’t now. “My family practitioner was a remarkable doctor, but that was a part of his world that I didn’t ever want to duplicate. I didn’t ever want to spend just a few minutes with a patient.”
Myth #2: Being on call 24/7 is exhausting and unsustainable.
When Dr. White told friends in his field about his intention to open a direct primary care practice that would allow patients to contact him with questions via phone and email twenty-four hours a day, seven days a week, the response was the same across the board: “Are you crazy?”, they asked. “How are you going to manage that?”
Dr. White admits to some hesitation early on, but now believes strongly that making himself available to patients 24/7 was one of the best decisions he ever made. “What’s incredible to me is that it has worked out just like I was told it would by other DPC physicians. If you give people ample time in the office, if you let people go through their lists of concerns and then address them, and if you enable them to call you during the day or contact you through the patient portal, it’s very doable”. And he speaks from experience. During the past three months, Dr. White hasn’t had a single negative experience with a patient who requested assistance after normal business hours. “I can count on one hand number of phone calls and issues that have come up after five on the weekends. Usually the ones that have apologized profusely”.
Dr. White thinks most people underestimate patients in this respect, but he’s glad that he gave people the chance to prove him wrong. “It’s totally contradictory to what one might think. If you have people paying by the month or by the quarter or by the year, you think human nature would motivate them to say: ‘Well I’ve payed for the year, I have a medical question, I think I’ll just call Dr. White’. But they just don’t do it. If they do contact me, it’s with many apologies and much appreciation. I have a DPC practitioner for coverage when I do leave town, so being on call 24/7 just isn’t issue. In fact, I’m so much happier doing it this way.”
Myth #3: Direct primary care practitioners only serve the wealthy.
Dr. White says the transition between health care models required some patient education on the costs and benefits of direct primary care. He tells the story of a local hairdresser who accused his practice of only serving the wealthy. “It turns out she charges more for a monthly haircut and color than we charge per month for 24/7 primary care services. I think a light bulb went off when I heard that, and I hope it will for her and others, too. I mean, she provides a very valuable service, but so do we.”
To ward off misconceptions and facilitate patient understanding, Dr. White started holding educational sessions at his office once a week so that community members could could ask questions about membership, services, insurance, and pricing. Many of his former patients immediately joined his new practice, but a few were more hesitant to make the leap. Dr. White noted that some who felt they were currently paying little out-of pocket for their healthcare were reluctant to switch. “The lightbulb goes off when they realize, despite how little they’re paying for their health care, it’s not what they want. They’re not able to contact their physician when they need to, they’re not able to see their doctor when they want to, and for a modest additional fee for primary care services, they can have a completely different health care experience.
Dr. White acknowledges that some people will not be able to afford his fees, but he doesn’t want that to prevent them from becoming his patients .“What I’ve done with some patients is say ‘Let’s work this out. I’ve seen you before, I want you here.’ I’ll ask them, ‘Can you pay $10 a month?’ And if they can, I say ‘Fine. Let’s do it. No questions’”.
Dr. White believes that it is the responsibility of the direct primary care community to develop sustainable ways to serve low-income populations. “I am pleased that there are some states where medicaid administrators are actually looking at providing comprehensive payment in a DPC mode with monthly payments. I suspect that if the paperwork and the bureaucratic hassles were minimized, there would be a lot of providers who would love to take care of people with very limited means. We need to figure this piece out. How can we make our practice available to anyone who wants to be a part of it?”
Myth #4: If it’s feasible, legal, and profitable, it’s automatically worth doing.
Though he is committed to making his services as affordable as possible, Dr. White does not dispense medication from his office, even though many DPC practitioners assert that it is an effective way to save patients time and money. In a small town like Cherryville, however, Dr. White says dispensing medicine would put his business in competition with local pharmacies, many of which are run by or employ his patients.“Local pharmacies play a valuable role in the community, so I think we need to be careful not to hurt their business”. He acknowledges that this may not be the best decision for everyone, but he is certain that it was the right one for him. “I’m all for affordable medication and convenience, but my local, privately-owned pharmacies already provide that, so why should I compete with them? I may be a minority in feeling this way, but, again, I belong to a small community and that’s our reality. That may not be the reality in San Francisco or New York City, but in a small town, you’re part of the fabric of the community and you need to think about everyone--not just your practice.”
Myth #5: It’s too late to try something new.
Dr. White encourages burnt-out doctors working in traditional practices or within a larger hospital system to give the Direct Primary Care model a chance, even if it terrifies them. He admits that it might not feel like the right decision at first. It certainly didn’t for him. “I was scared. I thought it was a crazy idea. I knew that other people thought it was a crazy idea. No one in this area had done it--I was the first to take the plunge--and I wondered, at times, if it would fail”. It didn’t though--Dr. White’s business is thriving. He has nearly two-hundred patients in just three months of practice, he sees between four and six per day, and he has never felt more excited to get up and go to work in the morning. “I hope what I’m doing will serve as a model for other sixty year old physicians who are feeling worn out, who feel that their career is over, who don’t want to to deal with the electronic health record, and who no longer want to be employed by a hospital system. I hope they will consider the direct primary care model and say: ‘Maybe I can step away, rejuvenate myself, rethink, replan, and then reenter the practice with the same passion and enthusiasm that I had when I was thirty years old’”. More than anything, though, Dr. White wants to share this reminder: “It’s not too late to have fun practicing medicine again”.