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The Direct Primary Care Movement: Our Generation's "1969 Moment"?

Many members of the PCP community recently attended the Direct Primary Care Summit in Arlington, VA. We'll be sharing their perspectives here over the coming weeks. Today a family medicine faculty physician weighs in. 

By James Breen, M.D.

The discipline of family medicine was founded on the idea – contrarian at its inception – that a generalist physician who knew his/her patients across the life cycle could serve as the cornerstone of the medical system and counter the reductionist approach of the burgeoning medical specialties of the time.  In the years after World War II, the rapid growth in medical knowledge and the return of physicians from the service heralded an “Age of Specialization” and a precipitous drop in the number of generalists.  The specialists of the mid-twentieth century underwent expanded postgraduate training that distinguished them from general practitioners, who lacked a structured residency preparation. 

In the 1960s, forward-thinking generalist physician-leaders such as Lynn Carmichael, Nicholas Pisacano and Gayle Stephens were conceptualizing a new specialty that did not define itself by a limited body of disease- or organ-system-specific knowledge, but rather was founded on a combination of biomedical science and humanism. This new discipline’s focus on human relationships was shunned by the prevailing academic medical community of the time, but eventually family medicine was legitimized as a discipline in 1969 with the founding of the American Board of Family Practice.  This new discipline, which included patients of all ages regardless of disease process, quickly gained favor among students, as evidenced by the explosion of family medicine residency programs from fifteen initially to over three-hundred eighty in the discipline’s first ten years.

In recent decades, American medical students’ rate of recruitment into primary care specialties has been anemic, with fewer than 50 percent of family medicine residency slots taken by US seniors.  No matter how you spin it, adding 89 more US seniors out of 3100 family medicine residency positions is not evidence of the surge in family medicine that many predicted as a result of the Affordable Care Act and the promulgation of the patient-centered medical home model.  For all the hope that these policy changes would reignite a sense of altruism and motivate students into primary care, the changes have not nudged the needle of enthusiasm in primary care enough to meet projected needs.

Among the graduates of the community hospital-based family medicine residency program where I teach, many practice something other than primary care upon graduation. In many cases, the comprehensive primary care they were trained to provide loses out to urgent care, hospitalist practice or fellowship training.

Paradoxically, I am filled with optimism and enthusiasm when I consider the future of primary care.  This optimism comes from the energy and enthusiasm swirling around direct primary care, a concept that restores the direct relationship between doctors and patients, without the involvement of third-party payer intermediaries.

Last month, I had the privilege of participating in the National Direct Primary Care Summit in Arlington, Virginia.  Sponsored by the Family Medicine Education Consortium with the support of the American Academy of Family Physicians, the summit brought together direct primary care innovators and early adopters to recount their stories and impart lessons learned for over 200 attendees. Refreshingly, the language of the conference centered on the values of the doctor-patient relationship, as well as the presumption that physicians are capable of partnering effectively with their patients without the hand-holding and intrusion of third-party payers, CMS guidelines or industry. 

Among those in attendance were a number of practicing clinicians of all primary care specialties, some faculty physicians, a few non-physician observers, and a prominent cadre of residents and medical students hungry to learn about how DPC might transform their future practices.  It’s this last group that got me to thinking of how this counter-cultural moment might be compared to the founding of family medicine as the nation’s twentieth medical specialty in 1969.

Like family medicine’s early leaders, direct primary care’s early adopters have the power of a simple, but paradigm-shifting, idea – the restoration of the direct relationship between doctor and patient – that resonates with both patients and physicians who yearn for a return to the relationships valued by primary care.  The founding generation of direct primary care has much in common with the transformative generation of Drs. Carmichael, Pisacano and Stephens.

Thus far, the intrigue and allure of the direct primary care movement seem to have been lost in the blind spot of the academic medical community, which tends to have a bias in favor of organized, large-scale reform propositions.  For this reason, many in the academic community have endorsed Accountable Care Organizations, the insurance-enhancing policies of the Affordable Care Act and state Medicaid expansion as the best ways to improve access and reduce the cost of health care.

However, after seeing the enthusiasm for direct primary care among medical students and residents at the DPC Summit, I am convinced that this movement will produce a grass-roots groundswell. Already the American Academy of Family Physicians has taken note and is offering workshops on how to transform conventional practices into direct primary care practices. In time, the eagerness and interest of medical students and residents will compel medical schools and residency programs to offer structured learning about the model, as we are doing at the program where I practice and teach.  As with the early days of family medicine, it’s the younger generation that will set the agenda on how to transform health care.  I am hopeful the teachers will be receptive to the lesson.

James Breen is a faculty physician at the Cone Health Family Medicine Residency Program in Greensboro, North Carolina.  He can be reached at

Check out other posts on direct primary care.

Posted by Sonya Collins on Jul 22, 2014 10:43 AM America/New_York
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