Political debates are often marked by moments. Moments that are long remembered. Gaffs. Body language. Five o’clock shadows. Things said. Things unsaid. And humor. 

So as I read and reread the recent articles by Drs Qiu, Lassey, and Farrago, I am reminded of the famous quip by Ronald Reagan to Walter Mondale in the 1984 Vice Presidential debate. 

I’ll paraphrase.

Kenneth, Vance, and Doug, I will not make age an issue in this important discussion about the future of DPC. I will not exploit your youth and inexperience in order to gain an advantage in this “debate.”

Of course, I am kidding. These colleagues are far brighter, far better writers, with far better ideas on this thing we call DPC. Their writings have made me think. And hopefully, many others to think as well. 

In my article “Taking Over The World? Or Just Driving Under The Influence?” I attempted to shine a light on those “Influencers” in our DPC community who by example or persuasion help move the DPC needle in many ways. 

However, I misspoke. I seemed to imply that entities like insurers and hospital systems and all those other “crooks” (as Vance described them) could somehow be influenced to do the right thing. Let me be clear. They won’t. And they can’t. They have too much to lose. They designed this mess we call health care. They will not help to clean it up. 

In my reflections, I have decided that this journey we are on is very much like the story of tobacco. Yes, another analogy run amok. So indulge me. Age does have its privileges, at least until Doug takes mine away. 

The scientific evidence for the dangers of smoking began to emerge in the 1950s, leading to the Surgeon General’s landmark warning of 1964. But up to then, the tobacco companies actually hired celebrities and professional athletes and even doctors to tout the virtues of smoking. Like looking cool and sexy. Mental clarity. Calmness. Seriously, this happened. 

Sound familiar? Despite very compelling evidence of the toxicity of the current healthcare system, the advocates and defenders of the status quo continue to stonewall and claim innocence. They pay well. They tell graduating residents there is no way they can practice medicine any other way. They get them hooked and they market well.

In 1960, almost half of the adults in the U.S. smoked. Today about 12 percent. Much progress has been made, but it’s been a long struggle. And meanwhile, we in DPC tend to be like former smokers. Intolerant. Critical. Impatient. Distrustful. We can smell the stench of a DPC threat miles away, like the odor of tobacco in a car or hotel room weeks and weeks later. 

Vance put it simply. No. Middle. Man. I get it. But I suggest we not let perfection be the enemy of the good, to paraphrase Voltaire. And here’s why.

I recently attended the NCAFP annual meeting in Asheville N.C. I must confess, I came home a bit discouraged about the future of DPC. During the weekend, I had the opportunity to talk DPC with many of my colleagues. Some who are excited and ready to take the leap now. Some who claim they are perfectly fine where they are. I think they are either in complete denial of the “evidence,” or just incurably addicted, or both. But far more of the physicians I talked to are indeed unhappy, looking for alternatives, counting the days down to retirement, but feeling stuck. They seem to grasp the virtues of DPC, but cannot get past such issues as guaranteed income, loan repayments, loss of benefits, fear of running a business, call and vacations, cutting their panel size, guilt over abandoning the less fortunate, and more.

It is my opinion that to reach this group, we may well have to violate our sense of perfection. We may have to violate our definition of DPC as a simple unencumbered relationship between physician and patient. We may have to get in bed with some version of the dreaded middleman to create more non-smokers. I know, that sounds unacceptable. 

But I am not suggesting anything new or radical. There are already many such examples in our midst already. The DPC physician who chooses a hybrid, not opting out of Medicare until they grow their DPC practice enough to pay the bills. Understandable, but not what I recommend. And strictly speaking, DPC-like. The DPC practice that depends almost exclusively on employers, or even just one large employer, to provide patients, and one monthly check. A successful business model. But classically speaking, DPC-like. The network that employs physicians in the DPC model, administration making the business decisions while the physicians “just care for the patients.” Again, an attractive construct. But DPC-like. In each, a middleman is lurking if not sitting in the den. 

But these examples illustrate the softer landing spots, the more tolerable and acceptable paths to DPC for more and more of our colleagues. Not perfect, but good. And we can do better.

It seems to me, before they come, we need to build not just a ballpark, but an even better ballpark. We need to solve those concerns above. Touting the virtues of DPC is not enough. 

How do we do that? 

I do not know. I defer to the creativity and imagination of my younger and smarter colleagues.  Deeper pockets? Creative financing? Consolidation of practices? Big data? A volunteer locum tenens option, crossing over state lines? For every solution I can think of, there are barriers and potential strings attached, barriers we may not solve and strings we may well regret. I do agree with Vance. We need to carefully study our next steps. To use Kenneth’s model, we need to become really good city planners. 

Which leads me to MY Holiday Wish. 

Doug was correct in his Holiday Greeting, that the friendships in DPC are indeed strong and unique. But I think more is possible. DPC has the best and brightest minds I know, but we are too divided, too siloed, too handcuffed by our own version of perfection and the future. And to those looking from the outside in, we are perceived that way. There is no need to mention specific entities or names, all of whom I greatly admire and appreciate. But they are all needed at the same table, at least figuratively and maybe literally. Maybe that table is the DPC Alliance? Perhaps a different kind of “Summit”? Maybe a unification of some other kind, to come up with a common plan, a common front, and a message which says while we are all pirates to some degree, we are together, planning cities very carefully, as one.

Not Hope, but Action. To recruit the ready. To influence the wiling. To break down barriers. To create tangible change. To fight the addiction. We might be able to do it faster and more effectively than the tobacco story if we do it together. 

Wouldn’t that be a nice Holiday Gift? 

Thanks for letting an old uncle speak his mind at the holiday table.