"I defended your honor last week,” my patient said.



“Thank you,” I said, curious. I hadn’t known my honor was under attack.



The defender of my honor was a woman who has been my patient for 15 years, who has gone through terribly difficult life situations, who has multiple health and emotional conditions, and who is on Medicare. Apparently, a nurse was in her home helping with the care of her mother, who is also a patient of mine. When the nurse asked the name of her PCP, my patient gave my name and the nurse reacted negatively. “Rumor has it,” the nurse told her, “Dr. Lamberts left his old practice so he could charge a lot of money and take care of wealthy people.”



“I stood up and shook my finger at her,” my patient explained. “You don’t know what you are talking about! Dr. Lamberts has taken care of us for years, and I wouldn’t ever have another doctor. He doesn’t charge a lot, and when I was having problems with money, he cut my fee in half.” She was agitated even talking about it, which made me smile. “That woman backed off because both mother and I were upset by what she said. I think she was afraid we’d attack her!”



The misunderstanding my patient defended me against is a common one, but one of many objections people have to the practice model. I faced these objections when I first wrote about my intent to do DPC, and recently these objections were again voiced by Timothy Hoff.



Initially, my response was simply to prove my critics wrong by building a practice that answered these questions. “It can’t be done” is best answered with “I did it.” But often these discussions take on the tone or tenor of a political or religious discussion. Defenders of DPC (including many DPC docs) are zealous in their defense, emotionally charged because this practice is life-changing. I regained my life and my love of medicine when I switched to the practice model. So when someone attacks DPC, it’s akin to having someone attack your spouse, your children, or your faith. But such discussions aren’t constructive, because the passion in the response makes it appear emotional, not rational.



So I will try to take a rational approach to the criticisms of DPC. I want to put aside passion, listen to criticisms, and address them reasonably. I’ll focus on the most frequent objections I hear.

Objection 1: DPC is Elitist



This is the objection faced by my patient (and Dr. Hoff’s article). The argument is that most people cannot afford the monthly fee, so only wealthy people can afford the care. In truth, I charge between $35 and $75 per month (not $50-$200 as said by Dr. Hoff), based on age. I do not charge more for complicated patients, management of difficult medical conditions. I am in sync with the majority of DPC practices in my billing.



As to the “elitist” criticism, there is a significant difference in the average income in my current practice compared to my old one, but it’s the opposite of what is suggested. I serve a lower income socioeconomic population than I used to, there are more self-employed, uninsured, and even unemployed patients. Why is this? I think it is the predictability and transparency of cost that makes DPC appealing. When an uninsured person goes to a traditional fee-for-service practice, won’t know the cost of care upfront, and labs and medications are potentially much more expensive than we offer.



There are some who cannot afford even the $35 to $75 I charge. Some of these (like my patient defender) I am able to help by discounting their price, either temporarily (for life circumstance) or long-term. As for others who cannot afford those fees, these problems are not mine to solve, as they are the societal problem of poverty, distribution of wealth, and unemployment that I cannot fix. DPC is a practice model, not a panacea.



Despite this, many low-income people value my care enough that they find the money to pay regularly. This includes the poor, as well as a sizable Medicare population. I believe that good primary care will often significantly reduce the cost by giving care to problems before they become serious (such as diabetes and hypertension).