This article appears in the August 2023 issue of The American Prospect magazine. Subscribe here.
By Stephanie Arnold, M.D., as told to Maureen Tkacik
I wanted to be an anthropologist. But one day in my junior year of college, I was in a bioarcheology class, and my professor pulled me aside and said, “Look, you are very good at this. But I want you to understand, you will get a Ph.D. and then you will be wait-listed to teach at community college.” I come from a working-class family; my parents got pregnant at 19 and my dad went back to school and finished college when I was 11. I was their firstborn daughter, I was class president, they had a lot of their own aspirations tied up in my future, and becoming a community college teacher, maybe, was not going to fly.
So I thought, I guess I’ll go to medical school because that’s … kind of like being an anthropologist? Here’s the thing with being a family doctor, though: All of your job options are going to have some sort of stigma attached. It’s not quite being an adjunct professor, but my husband, who is a chef, still has trouble comprehending what a thankless profession he’s married into.
When I was working full-time at an urgent care clinic at a strip mall in southern Virginia, someone came in for a laceration who turned out to be this guy I’d worked with at a sporting goods store in undergrad. So we caught up a little and at the end he was like, “So uh, are you going to get, like, a real job at some point?” I said kind of sheepishly, “Yes, I just have a nine-month-old baby and needed a paycheck.”
The good news is I started my own practice, part of a growing movement in medicine called direct primary care (DPC). It’s growing faster than I can even sustain, and I’ll soon have to quit all my day jobs. But to understand why someone with two very small children and $320,000 in student debt with a 6.8 percent interest rate would want at this point in her life to work 70-hour weeks, and take on even more debt, all to become a small-business owner, you have to know a bit about the jobs that do exist for millennial family physicians, and what that says about the state of American medicine today.
SADLY, OF THE JOBS I’VE HAD since completing my residency, the urgent care gig was the best. I’ve also done weekends at an independent abortion clinic where I’ve worked since undergrad. I’m obviously committed to abortion rights, but as a doctor it feels like an assembly line. I offer abortion services in my clinic now; there’s no six-hour wait and patients are welcome to bring their kids, who aren’t welcome at Planned Parenthood.
Until recently, I also worked full-time as a primary care physician for a company that specializes in something called the Program of All-Inclusive Care for the Elderly, or PACE. It’s a kind of Medicare Advantage plan for people who are dually eligible for Medicaid and Medicare. While all of the jobs felt kind of dead-end in their own ways, that one introduced new layers of dysfunction and cynicism I’d never imagined. Surprise: Private equity owned it.
I started medical school in 2011, full of idealism and optimism over the promise of Obamacare. But the health care system has gotten progressively worse every year that I’ve worked in it, probably because private equity firms keep acquiring new corners. The urgent care was an exception, it was part of a family business, founded by an emergency physician who actually cares about employees. When COVID came, they didn’t lay off a single full-timer even when volume fell off a cliff, probably in part because he was a big Trumper and was convinced the pandemic would “blow over” by the summer of 2020. Whatever the case, though, support staff and mid-levels stayed with the company for years, so they operated with a level of competence and efficiency you don’t see much these days.
Urgent care is an extension of emergency medicine, which was never my favorite. But it was a very coveted specialty when I was in med school that has completely collapsed. There were more than 500 unfilled residency slots in emergency medicine this year, which is unheard of, because private equity has turned it into an epic race to the bottom. No one wants to keep patients waiting 12 hours so they can get hit with a $10,000 bill.
The health care system has gotten progressively worse every year that I’ve worked in it, probably because private equity firms keep acquiring new corners.
In urgent care, I got a lot of patients who should have been at the ER but they were terrified of getting crushed by surprise bills. One woman came in for a mysterious infection no one had located and wasn’t responding to antibiotics, so I tested her blood and her white blood cell count was through the roof. That’s cancer. So I got her to the ER right away, where they performed an emergency Whipple procedure; pancreatic. Miraculously, she came back again the next year and told me the clinic had saved her life.
I found patients with undiagnosed lung cancer, a pulmonary embolism, sepsis, and a rare pediatric heart condition called Kawasaki syndrome. That kind of care can be satisfying, but it is also so depressing because all of those conditions could have been caught far earlier, more cheaply, and with a substantially higher chance of survival if these patients had regular relationships with physicians who were not too bogged down in paperwork to see them. Many had been misdiagnosed, mostly by people who weren’t actually doctors.
In most clinical settings, patients of a certain class don’t see a doctor at all, but a physician assistant or a nurse practitioner. I adore nurses, my mom is a nurse, but there’s between five and ten years’ extra education a physician has over an NP. The quality of medical judgment you’re getting just is not comparable, and it’s kind of crazy that the people who run things have somehow convinced everyone that it is. When private equity buys a medical practice, the first thing they tend to do is try to replace as many doctors as they can get away with with NPs.
MY FIRST RESIDENCY WAS RUN by a private equity firm, so I got an early window into what was in store for health care. The idea of family medicine training is that we practice medicine “cradle to grave.” By the time you’re finished with your residency, you can handle 85 percent of all medical concerns: prenatal care, labor and delivery, preventative medicine across all ages, pediatric visits, chronic disease management, acute concerns, reproductive health. If you look at some of the modeling for well-functioning health care systems, 50 percent of all their doctors are either family doctors or primary care physicians. Here, that number is less than one-third.
The way medicine is corporatized in this country makes it extremely difficult and thankless to practice family medicine as it was intended. In fact, it’s hard to even train a family physician, because community hospitals where physicians might do all those things under one roof or even in one neighborhood are bordering on extinction. There was a lot of media attention in the aftermath of Dobbs about abortion deserts, but in all those same areas you have maternity wards closing every few weeks, and now this vast effort to outlaw gender-affirming care. As a family doctor, it is difficult to separate the culture-war stuff from an ideological project to justify the deprivation of poor and working-class people of their right to health care, and the intimidation of doctors who advocate for them.
In 2014, when I was starting to look at residencies, there was a private equity–owned hospital chain that was pitching itself as some kind of savior of community family medicine. That was the pitch I got as a med student, that they’d found this formula for delivering better health care at lower cost by bringing it back to neighborhoods. They were launching a family medicine residency at one of the neglected community hospitals they owned in deep South Boston, as kind of a dry run. And I bought in!
The first month, they spent a lot of time training us on the need to mitigate racial disparities in health care. The hospital had a reputation for providing great care to Irish Catholics and not particularly good care to the Black and brown people who live in those communities now, and they painted the family medicine program as the cornerstone of an effort to rehabilitate this reputation. They said they were going to bring back inpatient pediatric care—they even had these big characters painted on the wall of what was supposed to be the peds unit—and they were going to have labor and delivery. When I interviewed, they made it seem like there was a lot of stuff that was still getting worked out because it was so new.
By the time I moved to Boston, it was just clear that none of it was happening at all. The hospital was owned by the same private equity firm that owned the manufacturer of the AR-15, and they had no interest in restoring community hospitals. We were initially supposed to do obstetrics (OB) at this hospital down the street, but then the private equity firm just straight up closed that hospital. So we ended up having to go 40 minutes south of Dorchester for the OB rotation, and most of us didn’t have cars. For pediatrics, we ended up having to go to a completely different hospital system up in Salem, fully an hour north of Dorchester.
It was just awful. And of course, it was a reflection of a broader system breakdown. But it’s hard to convey how much of a crisis it felt like as a first-year resident. You have a ton of education after four years of medical school but you only have a little bit of experience, and yet as a doctor you know you have this overwhelming amount of responsibility. Theoretically, it could take 20 years of training to really gain proficiency. The residency process is a kind of sacred, almost monastic tradition that is designed to give you all the training that you need so you can competently manage any problem, even and especially when you have no experience. When you come out of it, there’s almost a covenant with the community that you can be trusted with their medical needs. You’re painfully aware of everything you don’t know, and you’re really thirsty for this incredibly intense, compressed training in how to apply your education. And to be in a situation where you realize you were just not going to get there, it’s hard to describe how morally upsetting it was. It’s like this deep fear that if this training doesn’t do what it’s supposed to, I could potentially be in a situation to cause harm one day, which is the opposite of why we all went into this profession.
So we ended up filing formal complaints with the Accreditation Council for Graduate Medical Education and the hospital pulled the plug on the program, and I ended up at the Columbia University Medical Center, which was great.
ALL OF WHICH IS TO SAY that I should have known what I was getting into when I quit the urgent care clinic for a private equity–owned health care provider. But like I said, no one goes into family medicine for the awesome job prospects. I ultimately quit the urgent care because the Trumper owner was not great on COVID precautions, and someone assured me that the new job would involve a lot of telemedicine, which was good because I was 12 weeks pregnant and really trying not to get sick.
The company was a managed-care organization that worked by signing up senior citizens who were below certain income thresholds, then taking over their benefits and managing their conditions, with the idea of keeping them out of nursing homes for as long as possible. I think we made about $90,000 per patient per year, and with that money we were expected to pay for specialists, hospitalizations, physical therapy, home care, and whatever else they needed.
When I got there, the hub of the operation, the day center, had been recently acquired from a nonprofit. It had a kitchen and we held social events. People loved it. Well, that had to be cut, because we were losing money. Always, we were losing money. I don’t know if we actually were losing money, but if we were it was because we were brutally understaffed. The site administrator went to the mat to get the home care aide salaries raised to $12 an hour. I had to manage 260 super-complex patients, plus an extra 10 to 15 new ones getting signed up each month, with the help of two nurse practitioners.
These patients’ care could be better managed. I had one patient who’d been seeing a cardiologist for ten years for hypertension, and every three to six months the note was just copy-pasted from the last time. Most of my patients were seeing specialists for problems I could handle. That’s what happens in primary care; everyone is so overwhelmed they just refer you to someone else because then that’s one less thing they have to do.
But neglect can get really expensive. It was critical to make sure home care actually showed up to check on patients and shower them. I’d constantly be on the phone with families trying to keep their loved ones from getting admitted to the hospital unnecessarily, which honestly, can itself present a major health risk to a fragile patient if they are not properly staffed. There was a nursing home that we sometimes sent patients for “respite care”—if a family wanted to go to Disney World for a week, they could take grandma to a nursing home. But this nursing home was so short-staffed, at one point I visited and there were two nurses caring for 160 patients. So I put an unofficial moratorium on respite care.
If you’re one of my patients, I can give you the time to say what you need to say and listen to what you’re telling me.
We had all these metrics by which corporate monitored the patients’ “utilization” of health care. When a lot of patients went to the ER, there would be all this red on the charts, and when it got down to manageable levels, the chart would be full of green. I’d see the chart go red every time I went away for a few days and back to green whenever I returned, and that’s pinging away on your reptile brain, making you think, “I did a good thing!” But they didn’t really care about utilization. There was a center in another part of the state that actually had two physicians, and their charts were always green, and no one in the company took them seriously because it was so “overstaffed.” The organization was completely focused on enrollment: recruiting new bodies, getting new contracts, regardless of the health or lives of anyone they signed up.
We were only supposed to enroll patients with stable housing, no serious mental health or substance abuse issues, who did not present a harm to themselves or others. But all the time, they’d bring you patients who clearly did not qualify. The one time I successfully got a candidate rejected, it was because he literally had a huge scar on his face from a burn he’d gotten smoking a cigarette while using supplemental oxygen, and they finally relented on that one, because burn care is outrageously expensive. But I often wondered, where are they finding some of these people? In Pennsylvania, the sales team had literally started enrolling unhoused folks they met hanging out at a motel, and there was some internal discussion as to whether they were going to get into trouble for paying for these guys’ motel rooms so it would look like they had “stable” housing.
On the weekends, I’d moonlight at a local abortion clinic. The biggest thing people don’t get about abortion clinics is that anti-choice people get abortions all the time; some patients will refer to a five-week-old embryo as “the baby.” The shattering of that cognitive dissonance is precisely why you saw support for Roe surge after Dobbs. But in the moment, the patients are not happy, and many of them will take out their rage and shame on the doctor performing the procedure. For that and many other reasons, the doctor spends very little time with the patient. Nurses and support staffers get everything ready, do almost all the work, and you come in for six minutes. The rate for an aspiration abortion is $70, and I have heard it hasn’t changed since the 1970s, but on a busy Saturday the money is decent. It’s nothing I could imagine doing as a full-time job.
When I was pregnant, I would use the ultrasound to check in all the time. I self-diagnosed my second miscarriage that way; that was a hard day. Having kids is so hard even in the best of circumstances, but the ratio of joy to stress is so different when it’s wanted or planned. I’ve only ever refused one abortion patient: a couple who did want to get pregnant but the woman had a night of heavy drinking before she missed her period, and her husband was freaked out about fetal alcohol syndrome. I just said, you don’t realize it now but this level of anxiety you are feeling is the new normal, you are going to feel this way about everything for the rest of your life. Trust me, I am a parent. It’s very sad, but one of the most revolutionary things that happens at my clinic is the fact that we allow patients to bring their kids. Lots of patients have very young babies. Quite a few of my abortion patients have become primary care patients, which surprised me a little.
I FIRST HEARD ABOUT DPC during my second residency. It was and still is dominated by sort of libertarian-leaning men, who call it “free-market health care” because we don’t take insurance or Medicare. But they’re all committed family physicians who are just trying to do cradle-to-grave community care, as the founders of family medicine intended. The idea is that patients pay you a cash subscription fee of $75 or $100 a month, and in exchange you give them a full hour for your appointments, they have direct access to you, and when they need a drug or a blood test or an MRI, you find the cheapest wholesale price and provide it to your patients at cost, with a $2 fee for processing. So a complete blood count is $2.70, a metabolic panel is $2.70, a cholesterol check is $2.40. A chest X-ray is $47, and most ultrasounds are just over $100.
I am my own pharmacist, so other than Schedule II controlled substances, I can get their medications much more cheaply than they can even through GoodRx. More importantly for my patients, I keep a steady supply of the necessary syringes and applicators. For whatever reason, hormone replacement patients are constantly plagued by problems where CVS or Walgreens will have the drug they need but not the right vessels with which to administer them.
REBECCA D’ANGELO
Stephanie Arnold’s direct primary care clinic in Richmond
Dobbs definitely gave my DPC practice a boost in visibility and relevance. Indirectly, so did the pandemic. A lot of people realized they had gender dysphoria during the pandemic; a line I’ve repeatedly heard from patients is that “I couldn’t lie to myself.” A lot of people also realized they had ADHD. Silicon Valley responded with a lot of telehealth startups: You have Folx for gender-affirming care, Hey Jane for medical abortion, Cerebral for mental health. Patients got used to paying a subscription for these very specific medical needs and this very impersonal kind of care. Then Cerebral’s Schedule II business got essentially shut down after it was revealed that only five of their 1,600 prescribers were physicians. And Folx, while they’re a lifesaver to trans patients in rural America, as soon as you introduce any kind of comorbid conditions, they don’t want to take you on. Even with abortion, if you get mifepristone in the mail and you’re one of the unlucky ones with complications, you’ve got to start all over, or heaven forbid, go to the ER.
But if you’re one of my patients, you can feel safe knowing I’m monitoring the risks associated with your hormone therapy. If you experience complications with an abortion, I will do an aspiration for no charge. Most importantly, I can give you the time to say what you need to say and listen to what you’re telling me. And no one ever gets that with a primary care doctor because the whole medical profession is so weighted towards specialization that primary care physicians are forced into these practices where they’ll have 2,500 to 3,000 patients. The sweet spot for a DPC practice is 600. My practice has about half that, which is all we can handle until October because we’re only nine months old.
With 3,000 patients, you can’t actually know any of them. Your days are divided into five-minute installments during which you essentially operate as a gatekeeper to a rolodex of medical specialists until 5 p.m., after which you do three or four hours of paperwork documenting all the “care” you provided. It’s a job that could be replaced by algorithms, and algorithms are definitely determining how much you get paid, which is probably going to be between $30 and $60 for a primary care appointment. And if the practice gets $60, the doctor is not likely to see more than $30.
I could never take care of the patients I have in that kind of environment, because they often have some kind of trauma or chronic stress that is causing them physical pain, and you need time to work through that. I had a new patient I just saw a few days ago who has chronic fatigue. She came in very frustrated that no one was repeating her lab work. But these labs had been checked, and they were all normal. From her perspective, everyone had just said, “You’re normal, it’s fine. You just have kids, you’re tired.” But I was able to sit down and really talk through everything, and this person had recently experienced what they had sort of classified as insignificant trauma, but which was obviously taking a serious toll.
I took a deep breath and said, “Look, we can definitely check these labs again but I don’t want us to miss the forest for the trees here. You have something that is draining your battery all the time, and I suspect that that is the thing that is causing or exacerbating these symptoms.” And I was a bit nervous, because this is the moment where they’re either going to buy in, or they’re going to be upset that I didn’t think of another test we could order. And the patient said, “Wow, thank you, I didn’t really think of it that way but it really helps to hear you put it in those words.”
It was such a relief. Because this was precisely the kind of patient who used to just stress me out before, and now I feel like I can actually help them, no snake oil involved.
