Between Rebellion and Redemption: A Moral and Theological Critique of Direct Primary Care
John "Brewer" Eberly, Jr., MD, MA, Fischer Clinic, Raleigh, NC, Duke Divinity School, Durham, NC
“Suppose we did our work slowly / like the falling snow, quietly, quietly, / leaving nothing out.” So writes Wendell Berry.
Direct primary care (DPC) is one of the fastest growing practice models in the United States. At its heart, the movement seeks to heal a divide between patient and primary care physician that has been slowly widening for decades. As The New York Times Magazine reported in June 2023, direct-care models are motivated in part by the “moral crisis” of health care’s corporatization and bureaucratization in general practice, in which primary care clinicians feel increasingly alienated from the patients they hoped to know and heal.
In this paper, I will sketch a critical moral and theological analysis of the problems and promises of DPC, having worked within the model as a family physician since the summer of 2022.
In so far as direct primary care manifests 1) simplicity and affordability, 2) subsidiarity and availability, 3) solidarity and accompaniment, 4) seeing and agency—it seems to offer the kind of time, presence, attention, cost transparency, and direct access that patients long for. It seems to restore the delight of companionship, honor the limits and finitude of human creatures (both medical worker and patient), and bring back the joy of clinical reasoning to primary care practitioners who have long idealized Francis Peabody’s claim that “the secret of the care of the patient is in caring for the patient.” At its best, DPC is motivated by love, forbearance, advocacy, candor, and trust, with resonances from Catholic social teaching on health care reform, Jesuit tradition on availability as the marker of Christ’s ministry, and other moral commitments from the Christian tradition that I will celebrate and explore.
And yet, as one of our nursing colleagues once pointed out, “sometimes the falling snow isn’t very quiet.” There will be critique in this paper too. Direct primary care is not a silver bullet for a monstrous health care system. In so far as direct primary care is motivated by anger, avarice, more vacation time, carefully customized patient panels, and paramedical interventions that are not clearly health-restoring, it can become monstrous itself, such that its capacity to truly redeem primary care—let alone restore coherence to the doctor–patient relationship—will be greatly limited. DPC can manifest a dissident, neo-liberal cynicism that rejects authority, basks in free market competition, and perpetuates an erosive “red-pill” posture that exacerbates patient anxiety, encourages distrust, and worsens the divides in modern primary care rather than healing them—burning bridges with patients and other clinical colleagues rather than building new ones.
In this paper I will sketch a reckoning with DPC’s problems with 1) accountability, 2) anger and avarice, 3) alternative practices that engender health anxiety, 4) Medicare/Medicaid opt-out practices that manifest lack of attention to the poor (a critique common to concierge models that are said to only serve the “healthy wealthy”), and 5) idiosyncratic forms of local adaption that limit the model’s scalability. Are there moral and theological similarities and distinctions between direct primary, concierge medicine, boutique practices, and Federally Qualified Health Centers (FQHC) that are important to consider? Or, to borrow again from Wendell Berry, this time from his short story Fidelity, is DPC just another “coincidence of compassion and greed?”
Direct primary care is a promising practice for a corner of medicine that has been desperate for new life—especially as Family Medicine had its lowest MD “Match” rate in history in 2022. In this paper I will invite a critical conversation over where DPC is growing and going, somewhere between rebellion and redemption, where there is much anger but also much love and hope for a work where bewildered and beleaguered primary care doctors might finally care for their patients slowly, gently—quietly, quietly—leaving nothing out.
Direct primary care (DPC) is one of the fastest growing practice models in the United States. At its heart, the movement seeks to heal a divide between patient and primary care physician that has been slowly widening for decades. As The New York Times Magazine reported in June 2023, direct-care models are motivated in part by the “moral crisis” of health care’s corporatization and bureaucratization in general practice, in which primary care clinicians feel increasingly alienated from the patients they hoped to know and heal.
In this paper, I will sketch a critical moral and theological analysis of the problems and promises of DPC, having worked within the model as a family physician since the summer of 2022.
In so far as direct primary care manifests 1) simplicity and affordability, 2) subsidiarity and availability, 3) solidarity and accompaniment, 4) seeing and agency—it seems to offer the kind of time, presence, attention, cost transparency, and direct access that patients long for. It seems to restore the delight of companionship, honor the limits and finitude of human creatures (both medical worker and patient), and bring back the joy of clinical reasoning to primary care practitioners who have long idealized Francis Peabody’s claim that “the secret of the care of the patient is in caring for the patient.” At its best, DPC is motivated by love, forbearance, advocacy, candor, and trust, with resonances from Catholic social teaching on health care reform, Jesuit tradition on availability as the marker of Christ’s ministry, and other moral commitments from the Christian tradition that I will celebrate and explore.
And yet, as one of our nursing colleagues once pointed out, “sometimes the falling snow isn’t very quiet.” There will be critique in this paper too. Direct primary care is not a silver bullet for a monstrous health care system. In so far as direct primary care is motivated by anger, avarice, more vacation time, carefully customized patient panels, and paramedical interventions that are not clearly health-restoring, it can become monstrous itself, such that its capacity to truly redeem primary care—let alone restore coherence to the doctor–patient relationship—will be greatly limited. DPC can manifest a dissident, neo-liberal cynicism that rejects authority, basks in free market competition, and perpetuates an erosive “red-pill” posture that exacerbates patient anxiety, encourages distrust, and worsens the divides in modern primary care rather than healing them—burning bridges with patients and other clinical colleagues rather than building new ones.
In this paper I will sketch a reckoning with DPC’s problems with 1) accountability, 2) anger and avarice, 3) alternative practices that engender health anxiety, 4) Medicare/Medicaid opt-out practices that manifest lack of attention to the poor (a critique common to concierge models that are said to only serve the “healthy wealthy”), and 5) idiosyncratic forms of local adaption that limit the model’s scalability. Are there moral and theological similarities and distinctions between direct primary, concierge medicine, boutique practices, and Federally Qualified Health Centers (FQHC) that are important to consider? Or, to borrow again from Wendell Berry, this time from his short story Fidelity, is DPC just another “coincidence of compassion and greed?”
Direct primary care is a promising practice for a corner of medicine that has been desperate for new life—especially as Family Medicine had its lowest MD “Match” rate in history in 2022. In this paper I will invite a critical conversation over where DPC is growing and going, somewhere between rebellion and redemption, where there is much anger but also much love and hope for a work where bewildered and beleaguered primary care doctors might finally care for their patients slowly, gently—quietly, quietly—leaving nothing out.