“Don’t shoot the messenger.”

The origin of this adage is uncertain, but is often attributed to William Shakespeare (“The Bard”) in Antony and Cleopatra. In a particular scene, Cleopatra threatens to gouge out the eyes of a messenger who delivers the news that Antony has married another woman, to which the messenger replies: “Gracious madam, I that do bring the news made not the match.” 

So I politely ask that you not shoot me for bringing a warning. 

The vast majority of you are not old enough to remember the 1960s. If you are, you no doubt remember “Howard Johnson’s” restaurants. Those orange and blue eating establishments were found all across the U.S., often with a motel on the same property. In fact, by around 1970 there were over 1000 Howard Johnson’s restaurants in operation, representing the largest single restaurant chain in the country.

How was this success achieved? 

Howard Johnson was a real person, a visionary who anticipated that with the building of the interstate highway system, travelers would need a recognizable, reliable, and enjoyable place to pull in and eat while vacationing. He created an efficient business model. Regional locations cooked their popular menu items, froze them, then quickly shipped them to their restaurants in the area. Customers had their favorites; an especially popular choice was the clam roll. Howard Johnson’s were also known for their 28 flavors of very buttery ice cream, a novel concept at that time. Once a patron tried all the flavors, they received a free cone. 

Perhaps most importantly, Johnson recognized the need to keep children happy on family vacations. Children’s menus were colorful and fun; one such menu was designed to be converted into a mask. Children could join a birthday club to receive a birthday card in the mail annually. Often children requested to stop at the familiar orange and blue eateries. 

But after peaking around 1970, the number of Howard Johnson’s restaurants began to dwindle. Eventually, the Wyndham hotel chain bought out the majority of the properties, then gradually shut them down. By 2016, only one remained, in Lake George, New York. It finally closed in March of 2022. The end of an era. 

What happened? There were many factors. An oil embargo led to a gasoline crisis in the early 70s, dramatically reducing travel and family vacations. There was also a failure to innovate. Howard Johnson’s restaurants were designed for a family to pull off the road, come in, sit down, order, and enjoy. In time, families wanted speedier service, and eating on the run became more popular. When a McDonald’s franchise in Georgia first introduced the concept of a drive-through window, it became hugely popular. Other McDonald’s locations followed suit, as did other chains. But Howard Johnson’s never did. 

McDonald’s developed other ways to made the experience attractive to children. Instead of fun and colorful menus and birthdays, McDonald’s created the infamous “Happy Meal,” appealing to the taste buds of toddlers and thus establishing a brand loyalty for years to come. Even a 2-year-old in a rear car seat could see the golden arches in the distance and beg to stop. 

In effect, McDonald’s learned from the success of Howard Johnson’s and then beat them at their own game. 

So what does this have to do with DPC? 

DPC has grown and thrived since I started my journey 10 years ago. Then, it was estimated that there were only hundreds of DPC practices across the country; today there may be closer to 2000. It is heartening to witness the success of our various national meetings (such as the DPC Summit and “Nuts and Bolts”), the enthusiastic attendance at the presentations by Drs Sara Pastoor and Paul Thomas at FMX last month in Chicago, and the eagerness to learn at the Alliance’s Mastermind weekends in recent years. 

I see a bright future for DPC. More growth. More patients making the choice. More employers seeing the light. More physicians taking the leap. I see DPC becoming the Howard Johnson’s of health care in the next decade. Accessible. Refreshing. Appealing to families. Better.

But is there danger ahead? Could DPC thrive until it does not, eventually going the way of Howard Johnson’s? What factors could possibly lead to that? 

I only ask the questions. Don’t shoot. 

How scalable is DPC? Is one practice at a time really a formula for success? How can more of our colleagues opt out of Medicare in order to provide DPC care but not limit their moonlighting opportunities and future employment prospects? Will contracting with employers to enable growth and more predictable revenue streams erode the very attribute that many of us feel is the most valued of DPC: The personal and uncluttered relationship between physician and patient? 

Will emerging value-based initiatives, such as “Making Care Primary,” live up to their promise, and actually create the compensation and work-life balance DPC-wanna-be’s are seeking?  Will the big entities like Amazon and CVS, or even the large hospital systems, create a version of care delivery that resembles DPC enough to be hugely successful? Will we still be attractive when others begin to look like us? Will “single payor” finally come to fruition? Will unforeseen reforms and legalities make the DPC model obsolete? 

On a more practical level, will we solve the challenge of paying new physicians straight out of residency a truly competitive salary? Can we assist with their burdensome loans? What about benefits such as health insurance and retirement plans not only our employees, but for ourselves? As DPC colleagues raise their prices to achieve their financial goals, will we be tolerant, or regard them as practicing an “unacceptable” less pure form of DPC? Are we too attached to “this is how we do it”?

Will we, unlike Howard Johnson’s, continue to innovate? When in-office dispensing and transparent pricing become the norm rather than the exception, will we implement our own versions of the “drive-through window”? Will we be the ones who embrace AI, ChatGPT, and “health pods”, and somehow make them work for us? Or do we concede the potential of those technologies to others, and come up with our own? 

And lastly, brace yourself, guns down: Do we see ourselves as others do, through clear lens? At times, are we too “cliquish”? Too “good-old-boys’-club”-like? Can we be too “rah-rah,” thus minimizing how challenging running a business and living up to the expectations of our patients can be? Will the younger generation of physicians, who seem more risk-averse and (admirably) more interested in a balanced life, stay in the game, or will they drop aside and pursue other less-consuming interests? Will those of us (admittedly, mostly workaholics) winding down our careers be able to navigate our way and establish exit strategies that set the proper precedents for those who will face this process years from now? 

Put simply, are we in DPC – like Howard Johnson’s some 60+ years ago – too content, too sure of ourselves, too intolerant, and unprepared — to compete with the possible forces in our future? Will DPC one day, much to our surprise, be beaten at our own game, and simply fade away? 

I think not. I hope not. I am basically optimistic. I love DPC. I have made many friends and I owe so many so much. DPC saved my career, and probably my life. I am just asking some hard questions to stir up our thinking. 

Hold your fire. I do want us to keep serving clam rolls. And 28 flavors of ice cream. The things we do well. Let’s not abandon our basic values, but keep an open mind about change and survival. Maybe the DPC of tomorrow will not look like the DPC of yesterday. But that’s OK. Maybe if we are fully honest, thoughtful, and open-minded now, we can avoid the same fate of Howard Johnson’s. 

Thank you for reading.