We hear about DINOs more and more these days in Direct Primary Care. The ever-growing presence of the “DPC-In-Name-Only” movement. You might have seen discussions/debates on the DINO issue here on DPC News. Dr. Farrago recently discussed this trend on a podcast.
Over the last 9 years or so I’ve heard many DPC docs mumbling dissatisfaction regarding the phenomenon of “people” hijacking the term DPC. “People” in this context, can be anything from a free-market independent clinic not offering DPC benefits, to larger companies, mega-corporations, venture-capital-financed clinics, or even a small independent clinic staffed by a single unsupervised APRN. Regardless of who these “people” are, the overwhelming concern is that they will use the term “DPC” to attract patients, but bearing little to no resemblance to Direct Primary Care and authentic medicine with their model, sully “our” good name in a flurry of bad Yelp reviews and viral social media negativity.
I can’t say that I don’t feel this, to some extent. I mean, those of us who sacrificed piles of arguably dirty cash on the altar of professional freedom, autonomy, happiness, and the ability to sleep at night (knowing we do the best we can for our patients) tend to get a little lot defensive about what we’ve built. If you show me a DPC doctor who walked away from a hospital-owned job inside the system, started an independent DPC practice with affordable memberships, and who has operated it for 4-5 years–I’ll show you a doctor who would have made over 7 figures more in that same amount of time, staying inside the medical machine/cartel. Idealists who walk away from golden handcuffs like that are naturally going to get a little proud/protective about what they’ve built, especially if somebody else offers an inferior product, claims it’s equal, and labels it the same.
This protective instinct has escalated to the point where I have heard DPC doctors ask/discuss/debate the idea of copyrighting the term DPC. I’ve heard them suggest ideas for how to educate the public on what DPC is and what it isn’t. I’ve heard from those who want entities such as the DPCA to start a transparent “vetting” entity where a “real” DPC can earn some kind of seal of approval or merit badge/gold star so patients know they’re getting a real DPC doc, not some poser.
Basic understanding of the movement will tell you that none of the above will work. Of the many reasons, the most obvious is that we don’t even have a definition of “real” DPC. We have Dr. Eskew’s tried and true 3-point definition that beautifully serves the movement from a legal standpoint, but of course, it doesn’t dive into all the weeds that many would happily debate between a quality DPC clinic and somebody who’s just trying to get rich quick at the expense of the patient. We could debate what is and isn’t “true” DPC all day, and the only thing we’d agree on in the end is some subjective Potter Stewart-esqe version of “I know real DPC when I see it.”
That is not to say that most of us can’t agree on what DPC is not when we see it. In fact, I’d think it’s much easier to agree on what DPC is not. For example: It’s not hard to find “DPC” entities that:
- Employ lots of miserable “providers” (often no/few physicians) who are made to see 15-20+ patients per day and are expected to code diagnoses for insurance/data purposes
- Don’t cap patient panel sizes
- Run “band-aid stations” that refer everything
- Have a minuscule scope of practice
- Perhaps offer only telemedicine
- Claim to have “millions” of patients
- “Serve” scores of patients through some employer deal, the vast majority of whom have never met their doctor if they even have one, and many of whom don’t even realize they have that work benefit
- Etc. SO many more.
Looking at this bullet list, no DPC doc with a shred of dignity will disagree with the statement: “That’s not DPC, no matter what the sign says.”
So yes, as with any enterprise, there are true idealists among us. DPC docs who have sacrificed so much to do medicine authentically and meaningfully. And yes, just as with any successful enterprise, there are parasites. There are many kinds of parasites in DPC, but in this case, I am referring to the counterfeiters who simply slap a “DPC” label on a cheap copy of what idealists built, in order to siphon truckloads of patient, employer, venture capital, or private equity cash into their retirement account before sailing into the sunset, leaving destroyed lives and needy patients in their wake.
As usual, I’ve taken a 40,000-foot view and applied an analogy. When I first thought of “cheap copies,” the first thing I thought of was an expensive Rolex watch and the $50 copies you can buy from a sketchy-looking dude in Times Square. And to be honest, I have no idea how Rolex deals with the counterfeiting industry. But if I were them, I would embrace it. Here’s why:
If I were the CEO of Rolex, I would want my brand constantly associated with the concept that Rolex is the best there is. As such, it’s the brand that people will copy (nobody’s selling fake Casios). As long as I could go out and find a $40 Rolex on the street, I’d be happy. I’d only worry about counterfeiting when all the cheap copies on the street sported the trademark of my biggest competitor, because now my company isn’t being copied, and thus isn’t perceived as the best there is!
Perhaps I can think this way about my clinic because I am the CEO of it.
If unscrupulous people want to sell patients substandard care and label it DPC, let them. I mean, it sucks for the patients, but it won’t take long for the patient (or employer) paying a DINO to realize they’ve been duped into more of the same. My patients are out there in droves, raving about the care they get at my DPC clinic. I’m not alone. This is why many of us don’t have to advertise. I would expect the duped folks to listen to them, and seek out a real DPC doc ready to start a meaningful doctor-patient relationship.
I do recognize that this is a simplistic view of this problem. I recognize that DINOs have the money, power, and influence to ruin life for us all because they have the ears of lawmakers, policy wonks, etc. They could get a bunch of “pro-DPC” laws passed, then provide garbage care and get DPC outlawed, or somehow make it so DPC has to take Medicare to operate. Any number of nightmare scenarios are imaginable. But that happens, it’s ok. I’ll just rebrand. “No, your honor, per federal law, I stopped being a DPC doc after the Great-OneMedical-DPC-deathpocolypse of 2034. I’ve been a Direct Family Medicine Doc since then.”
PS. I apologize. I know I write lengthy editorials. It just occurred to me that this article could have been 10 words long. “Yay DINO’s. Because imitation is the sincerest form of flattery.”