I did not expect to enjoy family medicine. My father and grandfather were both family doctors, yet when I started studying medicine myself, I was quick to discover a polite disrespect for primary care. “Why would you go into family medicine?” was a common refrain. This, despite a shortage of primary care doctors that is only expected to worsen.

The reasons have been rehearsed many times: the burden of documentation, the pressure to shorten patient encounters, the focus on metrics, the distractions of integrating third-party payers. The primary care doctors I met during medical school seemed the most jaded and world-weary. By the time I graduated, I was still proud of my family legacy but had written off a future in primary care.

Nineteenth-century illustration of a doctor paying a home visit to a young patient. All etchings from iStock photos. Used by permission.

Around the same time, a physician named Ben Fischer was growing dismayed by what he was encountering as an internist in an insurance-based primary care practice. He called it the “physician reprogramming project,” in which he was being slowly malformed to focus more on quality improvement and financial throughput than on patient care, hurrying through his visits to check the bureaucracy’s boxes, despite sensing in his heart that his patients were crying out for more. Ben began to wonder what a doctor is for beyond the efficient and effective participation in the health care industry. More deeply, Ben sensed he was not becoming the good doctor he had aspired to be.

Ben returned to a novel he already knew well, Wendell Berry’s Jayber Crow, and found himself weeping. Jayber, the titular town barber, makes house calls to the farmer Athey Keith in the last months of his life, following a series of strokes, to cut his hair and be with him. Ben said to himself, “I want to doctor like Jayber barbered.”

So Ben wrote to Wendell Berry. Berry wrote back, “I am always delighted to hear from professionally dissatisfied physicians.” The Berrys invited Ben and his wife, Liz, to their farm in Kentucky, where they sat around their kitchen table and talked about how one might reform primary care. In 2016, the Fischers founded the clinic in which I now practice.

The Fischers had already discovered the direct primary care movement before meeting with the Berrys. Since then, direct primary care (DPC) has become one of the fastest growing models in the United States, offering unlimited primary care for a periodic fee, without billing insurance. DPC’s growth was driven in large part by primary care clinicians who had come to feel alienated from the patients they hoped to know and heal. By rejecting third-party involvement and redoubling attention to the doctor-patient relationship, the direct primary care doctor works solely for his or her patient for a flat fee, anywhere from $55 to $150 per month depending on the clinician.

In our practice, an average of $70 per month gives patients 24/7 access to their physician by phone and essentially limitless in-person visits. This monthly fee also covers simple in-office procedures and house calls. I recently visited two families with a dozen kids between them. It was a rowdy, intimate affair – requiring many paperclips and folders – but a gift to both me and these two families, who didn’t have to think about scheduling separate well child checks across the year.

We even offer inpatient care, following our patients in the hospital, as their hospitalists, without charging extra. Patients still need “catastrophic” insurance to cover their actual stay, but they experience our presence in the hospital as a work of solidarity. As one of Ben’s patients put it: “I found Dr. Fischer standing at the foot of my bed, waiting for me to wake up, just checking on me.… It made me feel very safe and cared for.” I’ll never forget seeing one of my own patients in the emergency room, where she said, “Thank you for coming. It has been so many strangers.” I’ve learned that having “hospital privileges” does not just mean legal authorization to work in a hospital, but the actual privilege of caring for my patients in the home, clinic, and hospital.

Our practice is not necessarily representative of the larger DPC movement, which is variegated and decentralized, undergirded by different moral assumptions, political postures, and theological convictions. Still, direct primary care has given us something of a rescue boat, which we can fill with our love. We strive to practice according to our conviction that the health and wholeness of our patients should be our sole work. We aim to know our patients well, know our profession well, and serve our patients directly in a way that offers them our attention, presence, and availability.

Because we do not bill insurance, we can link directly with nearby labs, pharmacies, and imaging centers to reduce costs. Together, the patient and physician can make practical, transparent, local decisions about what is best clinically and financially. We are able to serve patients pro bono if they can’t pay, which is not always possible in traditional primary care settings because it would violate insurance contracts. To make this a reality, we partner with local ministries, employ sliding scales, and even barter. Many are the days my partners and I have been paid in sweet potatoes.

Direct primary care is a good example of subsidiarity, the principle that it is best to push responsibility to individuals and communities through local organization rather than relying on larger, more remote powers. It assumes that those who are closest to their neighbors know best what needs their neighbors have. As Catholic surgeon Donald Condit writes in A Prescription for Health Care Reform, “subsidiarity helps to ensure that love does not remain a vague gesture of goodwill toward all coupled with a failure to practice charity toward actual persons with whom we come in contact.”

In many ways, modern primary care discourages subsidiarity. It prioritizes volume over relational depth. The average primary care doctor today takes care of something like 2,300 patients. But even following the reckoning of the health care industry, the number of patients a primary care doctor can actually accommodate per year within reasonable working hours is around 980. In the DPC model, however, such extrapolations are tempered by the actual experience of caring for suffering people, who often require time beyond what is clinically actionable. DPC physicians serve an average of 413 patients. I currently care for 604 people, some a few months old and some on the cusp of 100. The direct primary care patient receives over two hours of care per year compared to thirty-three minutes in traditional systems.

When patients sense their physician has structured a system that prioritizes relationship, other goods of solidarity emerge. In 2021, the British Journal of General Practice published a large study on continuity of care, based on 4.5 million people, which found that patients who had the same family doctor for just two years were 30 percent less likely to need to be admitted to the hospital and 25 percent less likely to die than those who had been with the same doctor less than a year. The likelihood of needing emergency care steadily dropped based on being known by your doctor.

In residency, getting calls in the middle of the night was difficult not because of interrupted sleep, but because I did not know my patient. It was clinically challenging to get a sense of the complexity of the story from which a stranger was calling out to me. I defaulted to CYA: “covering your ass.” Frank speech felt impossible. I also found that misanthropic and dehumanizing humor festered when we did not know our patients personally.

The inverse is also true. Strong relationships breed candor. I recently sat with two patients, one of whom interrupted me suddenly and asked, “Why don’t doctors talk to us normally? Like, why do you talk like a normal person?” I think her comment had less to do with me and more to do with this model, which cultivates honesty, and – blessedly – good humor. As a patient once told me, “I need you to be a shit screen.” (I said, “Let me grab my white coat!”)

Far from choosing an “easy” patient load, as I’ve been accused of by critics of DPC, we are choosing to be indefinitely on call, believing it is a critical feature of good medicine that a patient be able to see or speak with her doctor during her time of need. As the sociologist Charles L. Bosk writes in Forgive and Remember: Managing Medical Failure, “the time when medical students are around the most is the time in which they can do the least, just as the time when doctors can do the most is the time in which they are available the least.” Availability peaks during medical training and goes downhill from there. We are trying to reverse that.

The difficulty is letting go of the pretense that we can always accept more patients. We need to name our limits, like a farmer who knows there are only so many cows he can care for well in a given plot.

Now, when I get calls from patients in the middle of the night, I feel a deep sense of privilege and a kind of delight precisely because I recognize my neighbor. I finally feel not just “on call” but called. As one of my patients said after calling me late one evening, “This is why I am letting you care for me.”

In his classic essay “To Be a Doctor,” psychiatrist and medical historian Félix Martí-Ibáñez argues that “greatness is simplicity.” The simplicity of DPC clears away distractions to focus on the care of patients. And yet I am well aware that how we do that still depends on what we believe and value. Our particular practice draws inspiration from Wendell Berry, but also physicians such as Leon Kass, Francis Peabody, and Farr Curlin, who seek to refocus the clinician’s attention on health as the purpose of good medicine. As Curlin puts it, we are seeking “just medicine, for those who need it.” And ultimately, our work is not separated from our friendships and shared faith as three physicians who look to Christ as our hope and stay. While we do not make these “radical sources” apparent to our patients, they infuse all we do.

But I’ll confess, after three years of practicing in this place that I deeply love, alongside physicians and nurses I profoundly respect and admire, I still have lingering questions. Because we are no longer linked up with “the system,” I sometimes struggle to offer the care I aspire to. For example, it is often difficult to sustain long-term relationships with our most vulnerable patients. Disparities manifest in everything from mistrust to housing instability to a lack of transportation, making it difficult for us to maintain continuity. As one academic direct primary care practice found, despite launching with the explicit purpose of serving low-income and uninsured patients, “effective partnerships are crucial and elusive.” Tellingly, the practice closed because it could not sustain the volume necessary to support itself.

There are other critiques of DPC practices. For one, they are not required to participate in HIPAA or HITECH. Theoretically, they have less oversight because they are not obligated to participate in quality measurement programs or shared electronic health records, which could reveal problems with coordination of care, guideline adherence, or malpractice. In DPC’s defense, there are ongoing open studies to address this, such as the “Direct Primary Care Medical Malpractice Audit and Program Feasibility Study,” but these depend on the transparency of individual DPC physicians willing to submit information.

On the other hand, it is difficult for general physicians to hide unworthy work when they have intentionally embedded themselves in the community they serve. We are not rogue clinical cowboys; we’ve taken the same oaths and are held to the same professional standards. Our “quality measurement program” is our reputation in the community and among our clinical colleagues.

DPC is often conflated with, and dismissed as, “concierge medicine.” While concierge medicine developed alongside DPC in the 1990s, concierge practices usually charge a retainer on top of billing insurance, so are generally an option only for those who can afford “double charging.” DPC is not concierge, but the perception is hard to shake.

Most DPC practices do not interact with Medicare and Medicaid and therefore risk a lack of attention to the poor and elderly, leading to charges that DPC primarily serves the “healthy wealthy.” Then there is the awkwardness of exchanging money directly with patients who are your neighbors. I believe our model is just, but as bioethicist M. Therese Lysaught points out, Christians did not begin caring for the sick under a grammar of disposable wealth or “philanthropy attached to a profitable enterprise,” but with a love that transformed political and social arrangements into something new. Examples of this today include the Christ House for the homeless, the “money-free medicine” of the Bruderhof, and the Hawthorne Dominicans, who care for those with incurable cancer. Wendell Berry writes, “Work done in gratitude, kindly and well, is prayer. This is not for hire. You make yourself a way for love to reach the ground.” I long to work purely for love, but I am, in fact, for hire – paid to care.

At the same time, I think of how the ability of Christian bishops in the fourth century to offer hospice depended on the charity of wealthy Christians. I’ve wondered if I should have joined an FQHC (Federally Qualified Health Center) or some other “safety net” system to avoid this tension, but even in such places I’ve encountered primary care physicians who burned out because they replaced maximum production of insured patients with maximum production of impoverished patients. As a former FQHC clinician put it to me, they still often “follow corporate empire logic.”

A revealing cautionary tale is the Medicaid-managed direct primary care practice Qliance, founded in 2007 in Seattle as the nation’s largest DPC health care system, serving thirty-five thousand patients, half of whom were covered by Medicaid. Beguiled by political and investor pressures, Qliance filed for bankruptcy in 2018, despite showing early promise.

Direct primary care is, I’m convinced, less dehumanizing for doctors than other models. At the same time, I see in the movement a self-assurance that risks missing the work of reform left to be done. DPC physicians can find themselves attacking health care as business while becoming successful business people.

When my grandfather was a family physician, he wrote that we need young doctors of “integrity, energy, and charity.” It has proven far harder than I imagined to build a practice that sustains the physician’s integrity, restores the burnt-out doctor to energy, and cultivates charity.

Haggard generalists may be choosing direct primary care because they think it will make medicine easier. Direct primary care hasn’t made my work easier, though it has made it more serious, joyful, clear, and close. It has removed anonymity and the miasma of bureaucratic task-mastering, which can insidiously wear one down to the point of burnout, chronic moral injury, or resignation.

I have found that since I left “the system,” my awareness of my own failings has become more acute. Now, on days when I am frustrated, angry, or inattentive, I can no longer blame “the system.” It is, in fact, my heart that still needs to change, and my own clinical acumen that still needs sharpening. I am brought into a naked confrontation with my own lack of spiritual gifts. To riff on C. S. Lewis in Out of the Silent Planet, I find myself “an agent as well as a patient.” I strive for my work to be healing to patients, but it has been an unexpected gift to find myself healing too.

Direct primary care is not a panacea; it is a platform. Its success will depend on the character of the practitioners it enables and the local communities surrounding them. Freedom does not guarantee one will use that freedom well. As Erika Bliss, the mother of direct primary care, once quipped, patients looking to direct primary care must discern between those doctors running from something and those running to something.

In our practice, we are candid with patients. We are not just running from a broken system but running toward relationship. We are not a fine-dining restaurant but a local diner, in which you are not the only patron, but in which you can expect recognition, hospitality, and a good meal. You won’t get the luxury of having a private doctor in your pocket but rather the gift of having a doctor in the family, who can be reached when you are in need, without fighting a phone tree.

When Ben Fischer met with Wendell Berry, one of the first things Berry did was connect him to another local physician to discern together the rough path ahead. We remain deeply in need of our friends from other specialties and health care disciplines, along with our pastors and of course our patients, to hold us accountable to the good work we are setting out to do.

Take away the powers and principalities of modern medicine; reify the aims and double down on fidelity; and you are still left with the human heart, struggling to find the real work. Whatever the framework, we doctors are still left with the sick who come to us hoping for healing, until the fever of life is over and our work is done. As one of my first patients told me, “I look forward to dying with you.” That feels like a call to doctor the way Jayber barbered.