Over the last year, national news outlets have reported increased numbers of residents unionizing. All residents have employment through their teaching programs, so forming unions to fight against an unbalanced power dynamic makes sense; and in fact, the history of resident rights has roots in unionizing. Recently, however, a parallel story has come with residency union headlines which causes some concern: attending doctor unions. 

Paul Starr quotes Dr. Bayard Holmes (a doctor with an unfortunately awful career) in The Social Transformation of American Medicine:

“When the industrial revolution of the seventeenth century began it found Europe peopled with the independent tradesman…Now we find the homeless, tool-less dependent machine operators far removed from the people who furnish a market for the standardized product of their toil. The hospital is essentially part of the armamentarium of medicine…If we wish to escape the thralldom of commercialism, if we wish to avoid the fate of the tool-less wage worker, we must control the hospital.”

JAMA 1906

Doctors are largely finding themselves in the role of the “homeless, tool-less dependent operators.” Today, almost seventy-five percent of doctors are employed. Systemic changes in language reflect the diminishing role of doctors as they become just “providers” while nurse practitioners become “advanced practice providers.” Vertical integration has given insurance companies tremendous leverage to acquire doctors, and non-competes keep doctors chained to hospital systems. No wonder many doctors feel like cogs in a machine and find no other option but to engage in collective bargaining.

Part of the problem started just a couple decades ago with doctors ceding control to administrators who promised to “let doctors doctor” and take the annoying busy work from them. Along the way, the complexity of insurance billing and most of healthcare finance passed into the hands of administrators, swelling their numbers and leading to the infamous graph seen in most DPC talks; and, as Dr. Eric Bricker likes to say, in healthcare, the golden rule is he who holds the gold makes the rules.

Unlike the demise of the independent tradesman, doctors have two main traits that uniquely position them to take back their position.

1. Non Fungible: Non-competes exist because administrators know patients have loyalty to doctors, not hospital systems. Doctors all understand the importance of the doctor-patient relationship which serves as the foundation of our care. Patients aren’t products on an assembly line and doctors won’t treat them as such no matter how much pressure they feel from large systems.
   
2. Autodidacts: The type of person who gets into medical school and completes residency generally has the curiosity, smarts, and grit to do so. Practicing medicine may not transfer laterally to other industries, but the character traits of physicians make them some of the most versatile individuals, able to pick up new traits to face any challenges. 

Some people (myself included) make the tongue-in-cheek joke “But what do I know, I’m just a doctor,” a joke becoming less ironic and unfortunately more of a real statement. With the exception of some academics and hyperspecialists, today’s healthcare landscape does not allow for doctors to just doctor. Therefore, in addition to staying on top of medical knowledge, doctors should also learn something about the healthcare system landscape. 

Three bucket categories where doctors can have an outsized influence:

1. Business
2. Education
3. Legislation

DPC places physicians in the perfect position to affect any and all these areas. 

Business: DPC practices usually are owned and run by the clinician who also sees the patient. The model allows doctors, who generally have little or no business knowledge, to run their own small business in a world of vertical integration and hospital consolidation where doctors are told that business decisions are none of their business and even made to believe getting involved with the business side of healthcare is somehow unbecoming of the profession. As business owners, DPC physicians better understand the smoke and mirror games of hospital systems and insurance companies. They gain more ability to help their patients navigate not just disease but also the financial mazes of the healthcare system. Having to recruit patients gives them a pulse of their community and a better understanding of local health needs. Some DPC physicians also engage employers, who provide benefits to about 50% of all Americans, which puts them in a position to understand the intricacies and needs of the employer benefits world. The DPC model itself was started by a physician and as physicians in the model continue to run their practices, they will gain financial and operational skills which will empower them to lead innovation in overall healthcare finance and delivery.

Education: Virtually all medical schools have a need for clinical mentors and teachers, especially in family medicine. While insurance companies and hospitals can greatly affect the salaries of individual specialties, students will see doctors at work in their environments and the level of enjoyment or frustration the doctors experience. Currently, students who rotate in family medicine largely see burnt-out physicians, constantly running behind, with an unending mound of admin work. Even if every specialty paid the same, they would likely still choose something else, and currently they do. DPC physicians spend more time with patients, have better continuity, and, especially compared to referral mill practices, have a wider scope of practice. This makes DPC practices the ideal place for students to rotate and understand the true potential of good primary care. Mentoring and teaching at academic institutions can also demonstrate to students that they can be good clinicians and run their own practice, giving them a sense of empowerment early on which they will carry to residency and beyond. 

Legislation: When DPC started, the Insurance Commissioner of Washington state classified DPC practices as insurance products. Currently, the IRS considers DPC memberships a health plan which to them is synonymous with health insurance even though most states have laws classifying the model as not insurance. Most DPC practices help navigate prices for their patients, and in doing so, promote the price transparency movement. Policy and legislation affect everyone in various ways. DPC exists outside the current paradigm of insurance-based sick care, so to help legislators and policymakers understand this new reality, DPC doctors simply need to share what they are doing. Active participation in the legislative process helps remove misconceptions and promotes innovation and more creativity in the DPC space. 

The role of the physician has evolved over time and the evolutionary journey, like all natural processes, has been a winding one. Physicians only really started gaining prestige and trust a little over a century ago. Some of the status built over the last hundred years has eroded in the last few decades which leads to yearning for yesterday and mourning today. But in order to celebrate a better tomorrow, physicians need to reclaim the autonomy they so willingly gave away by understanding and engaging the greater healthcare ecosystem. Sometimes to be a doctor requires being more than just a doctor.