Careers in Family Medicine: Direct Primary Care

We are continuing our blog series, Careers in Family Medicine. Each week, I will highlight a family physician and their career path. Each one will share their pearls. So far, we have highlighted examples of Rural Practice, Value Based Care, Academic Medicine, US Department of State, and Multi-specialty group and Leadership.. This week, we take a look at a Direct Primary Care approach highlighted by Dr. Adriana Raus.

Adriana, tell us about your journey from residency to your current DPC practice and coaching.

Thank you for the opportunity to share my journey with you!!!

I was born in Romania and trained there to become a medical doctor. Subsequently, I moved to the US for a match in FM residency. As an international medical graduate, I had to secure an employed position in an underserved area to satisfy my J-1 waiver visa requirements. I joined a small local rural hospital in Central Michigan, where I practiced full-spectrum family medicine without OB. I immediately took over a large outpatient practice, heavy in geriatrics with complex medical problems and continued to admit my own patients in the hospital. The first two years for me were definitely the period with the steepest growth as a physician. When I finally got comfortable knowing my patients and stabilizing their most urgent health issues, I realized that the battle was futile. The system was created in such a way that no matter how efficient I was, how many protocols I had in place, or how good my tech abilities were, it was never enough—never enough patients seen, never enough time to address pressing issues, and never enough time to get to know them. I felt the dread of missing an important diagnosis, and I knew my beloved patients and their families would be forever scarred. I remember a case with a 45-year-old male factory worker who came in with his 10-year-old son for his asthma follow-up. During the visit, the father mentioned his concern about the numbness on his tongue lately. I wanted to address the issue, but no appointment was available for another month unless I double-triple booked myself and split the other appointment time in half or thirds. I could not promise myself that I would read up on the causes of isolated tongue paresthesia because I knew there was no time. I had to finish charting and also had a family at home that needed me afterward.

It was in that moment when I realized that I couldn't see myself practicing medicine like this for another 20 years at least. After rounding in the hospital and seeing 30 patients each day, plus answering messages and refills, signing papers, attending administrative meetings, and calling back results, there was nothing left of me for myself.

I had to think long about my journey as a doctor, my role in healthcare, and my future as a human. I knew I needed to find a different way to practice my passion. I thought about finding a different employed position, I thought about doing hospitalist work—but I really, really loved my continuity patients and creating those long-term relationships with multiple generations of families, understanding socio-dynamics, and being there for them when they got sick, when they got better, and when they lost a dear one.

I went into medicine to practice prevention and take care of their health, but I ended up providing sick care and burning the candle at both ends in the meantime. In my searching endeavor, I came across a conference about direct primary care, a new model of healthcare that I thought was kind of old-fashioned, where the doctor has a direct relationship with the patient without a middleman interaction. It was a place where you take the time to develop a relationship, explore all the health concerns, focus on prevention, lifestyle changes, and advise the patient about the optimal way to improve their health and well-being. I was curious to see what it was all about.

What surprised me at that conference was that most physicians were relaxed, smiling, and enthusiastic about practicing medicine. At the end of the conference, I decided that this is the way I want to practice medicine; I will make it happen as soon as possible.

Now you may ask, what is DPC? 

Direct Primary Care (DPC) is a healthcare model that focuses on providing primary medical care directly to patients without involving insurance companies or other third-party payers. Instead, patients pay a monthly membership fee, similar to a gym membership, to their DPC provider, giving them unlimited access to primary care services. This model allows for longer appointments, more personalized care, and a stronger doctor-patient relationship. Additionally, many DPC practices offer discounted prices for medications and labs, further reducing the cost burden for patients.

Key features of direct primary care include:

1. Membership-based: Patients pay an affordable set fee directly to their DPC doctor, usually on a monthly or annual basis. This fee structure allows for a more direct and personalized relationship between the patient and the doctor. 

2. Comprehensive primary care: DPC doctors offer a wide range of primary care services, including consultations, physical examinations, vaccinations, minor procedures, and basic lab tests. They focus on preventive care and spend more time with patients, allowing for better continuity of care.

3. Accessibility and convenience: DPC doctors often offer extended office hours, same-day or next-day appointments, and increased access to healthcare providers through phone calls, emails, or telemedicine. This approach aims to minimize unnecessary emergency room visits and improve the overall patient experience.

4. Transparent pricing: we offer transparent pricing, clearly outlining the costs of membership and additional services. This allows patients to know upfront what they will be paying for and avoids surprise medical bills.

5. Reduced reliance on insurance: Direct primary care operates outside the traditional insurance-based healthcare system. Patients often use health insurance plans primarily for catastrophic events, hospitalizations, or specialist care. By bypassing insurance for primary care, DPC can lower costs significantly and increase accessibility for patients.

DPC does not cover specialty care, hospitalizations, or other advanced medical services, which would typically require separate insurance coverage.

During the first DPC conference, I connected with numerous physicians who were also involved in the direct primary care (DPC) model. They provided valuable advice and motivation to start my own DPC practice. Six months later, I established my DPC practice in Lansing, Michigan. As a physician, I quickly realized that medical school and residency did not prepare me for the business aspects of running a practice, advertising myself, or introducing a new healthcare delivery concept. Since I was the first to do so in my city, it was an entirely new idea for the community. 

Building my practice gradually brought me joy as I got to know my patients and understand their unique circumstances. Despite limited resources, I worked diligently to address their chronically neglected health issues through lifestyle and motivational interviewing techniques. However, for some patients, no matter how much time and effort I invested, we made no progress in managing their diseases. It was frustrating to seem to be more invested in their improvement than they were.

Realizing that I needed a different approach, I delved into studying habit change and disease management through health coaching. In 2021, I enrolled and became a certified life coach. This not only became a tool to help my patients but also played a significant role in my own healing from burnout. I learned to listen more and talk less, allowing patients to explore their limiting beliefs about disease and health. Shifting the focus to what was going well in their health, rather than solely addressing what was wrong, made a substantial difference.

Currently, I incorporate life coaching into every patient visit, providing webinars on various health-related topics for my patients on a weekly basis. This approach has strengthened my relationship with patients and has made me a more balanced and effective doctor.

Now, as a practicing DPC physician, I can truly say that I have found my calling. I have the time and freedom to provide comprehensive care to my patients, addressing their immediate needs as well as focusing on preventive care and overall well-being. The joy and satisfaction I experience from practicing medicine in this way are unparalleled. In addition to my clinical practice, I also have the opportunity to coach and mentor other physicians who are interested in transitioning to the DPC model. It is incredibly rewarding to help others navigate the process and see them flourish in their new practice.

Overall, my journey from residency to DPC practice and coaching has been transformative. It has allowed me to rediscover my passion for medicine and make a positive impact on the lives of my patients and fellow physicians. I am grateful for the opportunity to practice medicine in a way that aligns with my values and provides the highest quality of care to those who need it most.

What were the key lessons you learned prior to DPC?

1) Family medicine specialty has a unique position to care for the whole family, and taking care of one family member is reflected in the health of the extended family and community.  

2) Traditional insurance-driven medicine is not always having the patient's best interest in hand. The people delivering the care are key in protecting and providing the care.  

3) Patients seek care when they are ready. They will change when they are ready. Forced healthcare is not serving anyone. (aka "physicals to get insurance discount")

4) The doctor has a lot of influence in the health of a patient but is never more influential than the patients themselves.  

Can you tell us about any other differences or downsides that you observe with DPC? 

Some traditional boundaries may get blurred. You will be the person they call/message with a lot of problems that are not always theirs and not always medical. They will share with you their joys and sorrows from losing a pet to their relative in a different state doing a miraculous recovery from a stroke. It’s all part of the human experience, and the connection is beautiful.

Some are underestimating the time and effort it takes to do the "non-medical" part: (administrative, marketing, and planning). The income can be down in the beginning, and that may affect physicians especially with student loans. The journey is hard and fun and easy and scary and hard again, but such is life, and is so worth it!

What do you see as the most valuable aspects of DPC practice?

The most valuable aspects of DPC practice are the independence it provides and the freedom to practice medicine in a way that best suits the patient. In DPC, being able to invest more in finding the right specialist for each patient and collaborating with them for optimal therapeutic results is a significant advantage.

Treating patients regardless of their insurance status can be challenging, but often avoiding insurance proves to be the easiest and most cost-effective solution. A common DPC practice gives scholarships for up to 10% of their patients that otherwise wouldn’t be able to afford DPC membership due to socio-economic or severe diagnosis reasons.

Another valuable aspect is building strong relationships with patients, going beyond their medical numbers, and getting to know their families. DPC allows for flexibility in providing care in various settings tailored to each patient's needs, whether it's through telemedicine, workplace visits, home visits, or communication via text or email. Distance is not a barrier, as I remain their doctor whether they are next to me in the office or thousands of miles away. The ability to adjust and accommodate patients' schedules is also crucial. Longer visits of 1-2 hours are not uncommon in DPC, and even home visits for entire families are possible. The focus is on making it work and adapting to both the patients' lives and mine.


How does someone even get started?

To get started in the DPC practice, one valuable step is to learn from experienced professionals who are already doing it. The DPC community consists of approximately 3,000 physicians across every state and many of them are willing to offer advice and support. There is a wealth of free content available on platforms like YouTube, including recorded DPC conferences that provide hours of valuable insights.

Additionally, the DPC Alliance, a nonprofit organization for DPC physicians, offers a resource called "DPC University." This library of resources provides specific guidance on how to start and grow a DPC practice. As a disclosure, I am a volunteer board member for the DPC Alliance and organizer of the upcoming DPC Summit in June 2023.

By tapping into these resources and engaging with the DPC community, aspiring DPC practitioners can gain knowledge, guidance, and support to embark on their DPC journey successfully.

What other tips do you have that you think will be helpful for the readers to consider who are looking at the best ways to enjoy their chosen careers and all of life?

Medicine is a skill that you acquire and become an expert at, and it can be utilized in various settings and ways. While many individuals choose traditional employment in insurance-driven healthcare systems, there are numerous alternative paths to providing patient care. If you find that existing options don't fulfill your heart's desires, don't hesitate to create your own path and bring it to fruition.

Patients are in need of care, whether it's in a university setting, on a cruise ship, or in a refugee camp.

Seek out the environment that excites you and ignites your passion for medicine. Be open to exploring new avenues until you discover your ideal setting. Remember that your career is just one aspect of your life, and it shouldn't consume your entire being. Make room for other passions, family, and hobbies, ensuring a well-rounded and fulfilling life beyond your professional endeavors.


Thank you so much for sharing your wisdom, how can people find you or learn more? 

I strongly recommend tuning in into a DPC conference.

DPCA University from DPC Alliance. 

Multiple recorded sessions of DPC conferences from previous years. 

We have an independent DPC NEWS newsletter.

We have a DPC colleague that creates a podcast about different DPC journeys. 

You may locate a DPC doc close to you and call them to see if you can visit their practice and ask questions. DPC Frontier has a map with all open DPC practices in US. 

You can always email me if you have questions about DPC and I will try my best to help you. 

Wow, such a great detailed lesson on Direct Primary Care. I'd love to know what you found helpful.  

Next week, we'll dive into being family physician in an FQHC with OB with Dr. Charlie Procknow.

Until then, have a joy-filled week! Tonya