The Hardest Step
By Dr. Zachary West, DO:
I started my journey in medicine and entered medical school when 25 percent of United States physicians were employed by hospitals or corporate health systems. That number rose to 44 percent by the time I completed residency, 74 percent by the time I completed fellowship and presently stands at 78 percent.1 Physicians have a responsibility to patients while big healthcare entities have a fiduciary responsibility to shareholders and it should come as no surprise that conflicts might arise between these two competing elements.
Throughout my training there seemed to be an assumption that upon graduation one would pursue employment. A state of growing codependency between physician and big healthcare was taking place during my years in training. Providing patient care meant learning to navigate the complexities of the modern system with a growing reliance on big healthcare. Education time was dedicated to billing and coding in an effort to ensure requirements of insurance companies were met and payments maximized. The use of productivity measurements facilitated the acceptance of big healthcare’s definition of what it meant to be a “good doctor.”
I joined the employed physician statistic following residency and ultimately faced things for which my training had not prepared me. Attempted coercion, intimidation, non-disclosure orders and even blacklisting by big healthcare were just some of those experiences in my early career. I had entered medicine in order to provide care to patients and was faced with the harsh discovery that my objectives were not the same as those of big healthcare.
It was during my fellowship training that I spent time with a direct primary care (DPC) physician and first discovered the DPC approach to patient care. I was intrigued by an ability to provide the necessary time for each patient case and the ability to practice medicine without worrying about a need to satisfy insurance requirements or dictates of big healthcare. Being a “good doctor” was defined by the patient and again meant providing good medical care. In an era where the number of employed physicians continued to rise, however, DPC was a daunting concept for a young physician and seemingly ran counter to the experiences of my training.
My relationship with big healthcare ultimately left me feeling defeated. I recognized that the only way for me to continue in my profession and to maintain a clean conscious was to truly be independent. Student loans, lack of equipment, lack of office space, the fear of failure, fear of the unknown were just some of the elements prompting my hesitation and consternation. I will forever remember the day I phoned the direct primary care physician from my fellowship. He listened empathically and provided a simple yet meaningful reply, “The hardest step is the first step.”
It has been nearly two years since I opened my direct primary care practice in my hometown and my practice continues to thrive. I started with nothing and brought a novel approach to medicine to the region. The proverbial chains of big healthcare were finally broken and my liberation came when I took that first step and decided to become an independent physician.
As a young physician in practice and a new member of the DPC community, I have answered calls on more than one occasion for a physician colleague seeking advice on their own struggles with big healthcare. To the reader who is a direct primary care physician, I encourage you to extend grace and compassion, particularly towards those young physicians trapped within the only system most have ever known. To the reader who is a physician facing their own challenges with big healthcare and contemplating DPC, the hardest step is the first step.
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