Tag: family medicine

Direct Primary Care: Access Problems in Today’s Clinics

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

When I talk to patients about how they access care, I hear a lot of frustration with the way primary care is delivered today. People describe having to wait weeks for a routine appointment at a clinic owned by a large corporation. They tell me they freeze up when they see a copay, even for simple follow-ups. And they often end up sitting in urgent care lines for something that should have been sorted out by a doctor who knows their story.

That experience is not unique. Many traditional primary care clinics are now owned or managed by big health systems and private equity firms. Those organizations run medicine like a business, with incentives tied to volume and billing rather than the patient’s whole-person health. That often means large patient panels and shorter visits. It also means that, with limited appointment slots and competing demands, a visit may not come soon enough when someone needs timely care.

Direct primary care (DPC) grew out of that dissatisfaction. In the simplest terms, DPC is a model where patients pay their doctor a flat membership fee, usually monthly, for direct access to routine and preventive primary care without billing insurance for every visit. You don’t see a copay or deductible for that visit the same way you do in the traditional system. What you pay upfront buys you ongoing access to your clinician for check-ups, chronic disease management, urgent but non-emergency care, and preventive services. It’s a direct contract between you and your doctor, not a third party like an insurer in the middle.

One of the most striking differences between DPC and a corporate primary care clinic is access. In a typical insurance-based practice, panels can be very large. Physicians might have multiple thousands of patients, which contributes to long waits for appointments and brief encounters when you finally get in. In contrast, many DPC practices purposefully keep panel sizes smaller, sometimes by orders of magnitude, so patients can get same-day or next-day visits and more time with the physician.

That difference matters to patients trying to manage chronic illness or catch problems early. I’ve had patients tell me they opted for DPC after a night of struggling with a new symptom and knowing that at an urgent care clinic they would only get episodic treatment. They want someone who sees the full picture of their health year after year, not someone who treats symptoms in isolation.

That contrast between DPC and urgent care is important. Urgent care excels when a child’s flu symptoms spike at 3 a.m. or when someone twists an ankle. It’s great for acute, episodic problems, and you don’t need an appointment. But those clinics are not set up to build a longitudinal understanding of you as a person: your past medical history, your family health history, your social context, your chronic disease patterns. Urgent care providers are trained to stabilize and treat the immediate issue. They rarely have time or the patient record in front of them to integrate your whole story into a care plan.

Direct primary care, on the other hand, puts continuity and relationship first. If you see your doctor regularly, they come to know your lab values alongside your life stressors, your diet, your work, and how your family affects your health trajectory. They can tailor plans accordingly, and they are available when you need guidance early on, often avoiding a need for more costly or fragmented care later.

Here is a hypothetical, not an actual patient encounter: a persistent cough that won’t clear up. In urgent care, a patient might get evaluated and sent home with instructions to rest or a prescription for symptomatic relief. In a DPC clinic, the doctor can say “let’s see you today,” review the full chart, adjust chronic meds if needed, and schedule a follow-up next week. That continuity can make the difference.

DPC is not perfect for everyone. Membership costs money, and that cost has to be weighed against sporadic traditional visits, though many patients find that predictable pricing encourages them to seek care early instead of waiting for a problem to become urgent. It doesn’t replace insurance. Hospitalizations, specialized care, and emergency services still need coverage of their own; DPC handles primary care, not surgeries or specialist procedures. Geographic access is a real constraint too. Not every area has a DPC practice within reach, and for some patients that alone rules it out.

Advocates of DPC argue that the financial predictability and relationship-based care improve satisfaction. Members appreciate straightforward pricing without surprise bills. Physicians appreciate less paperwork and more clinical time with patients.

The model works best for primary care needs alone. It doesn’t cover everything, and patients should pair a DPC membership with adequate insurance for catastrophic events.

Where I think the DPC pitch oversells itself: it markets convenience as though it solves a shortage problem. A membership fee doesn’t create more primary care doctors in a region that doesn’t have any. It only helps if a DPC practice already exists within reach.

I ran a concierge practice in 2010 and 2011, before anyone was calling it direct primary care. Patients felt less rushed and more heard, and that part was real. They call or message with early symptoms and get help quickly. That often prevents minor issues from becoming major ones. It’s a different rhythm of care, one that reflects the old-fashioned doctor-patient relationship many of us went into medicine to preserve. If a patient values that kind of access and ongoing partnership, and understands the limits of what DPC covers, it can be a powerful option that keeps them healthier and more engaged with their care.

Scott Rennie, D.O.

Sources

American Academy of Family Physicians (AAFP)

https://www.aafp.org/family-physician/practice-and-career/delivery-payment-models/direct-primary-care.html

Direct Primary Care Coalition

https://www.dpcare.org/what-is-dpc

National Academies of Sciences discussion mentioning DPC models

https://nap.nationalacademies.org/read/26183/chapter/5

Access, wait times, and problems in traditional primary care

Merritt Hawkins Physician Appointment Wait Time Survey

https://www.merritthawkins.com/news-and-insights/thought-leadership/survey/physician-appointment-wait-times/

Association of American Medical Colleges primary care shortage data

https://www.aamc.org/news/press-releases/aamc-report-reinforces-physician-shortage

Corporate ownership and consolidation in healthcare

American Medical Association on private equity and consolidation

https://www.ama-assn.org/delivering-care/public-health/what-doctors-should-know-about-private-equity-medicine

Health Affairs on private equity and physician practices

https://www.healthaffairs.org/do/10.1377/hblog20230207.10575/full/

New England Journal of Medicine perspective on private equity in healthcare

https://www.nejm.org/doi/full/10.1056/NEJMp2102339

Urgent care role and limitations

Urgent Care Association patient education

https://www.ucare.org/patients/what-is-urgent-care

Agency for Healthcare Research and Quality on primary care continuity

https://www.ahrq.gov/ncepcr/primary-care-measures/continuity.html

Direct Primary Care outcomes and structure

Journal of the American Board of Family Medicine review of DPC

https://www.jabfm.org/content/28/6/793

Health Affairs article on DPC patient experience

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05032

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Unlabeled blister pack of six white oval antibiotic tablets beside a plain paper pharmacy bag on a kitchen table

I hear it almost every day now. “I think I just need a Z-Pak.”

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

Scott Rennie, D.O.

Sources:

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. 2012;366:1881-1890.

Sax PE. How the Z-Pak Took Over Outpatient Medicine. Substack lecture notes and essay.

Svanstrom H et al. Use of azithromycin and death from cardiovascular causes. New England Journal of Medicine. 2013;368:1704-1712.

FDA Drug Safety Communication. Azithromycin and risk of potentially fatal heart rhythms. US Food and Drug Administration. 2013.

CDC. Antibiotic use in the United States: Progress and opportunities. Centers for Disease Control and Prevention.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Perimenopause and Menopause Symptoms and How to Manage Them

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

Menopause comes up on my schedule most weeks, and patients still arrive unsure what to expect from it. So it helps to start with definitions. Perimenopause is the transition before menopause. Hormone levels fluctuate, cycles become irregular, and the phase can run several years. Menopause itself is twelve straight months without a period. The average age in North America is around 51.

Symptoms vary more than most patients expect. During perimenopause, bleeding may be heavier some months and absent others. Hot flashes and night sweats are common. Some women notice mood changes or brain fog. Others raise vaginal dryness or discomfort with intercourse, usually only after I ask directly. Sleep problems come up constantly, and they are often just night sweats wearing a different hat. In full menopause those symptoms can continue, though bleeding stops for good. Skin and hair changes, weight shifts, and urinary urgency show up here too.

One patient in her late forties came to me worried she had a thyroid problem. She felt “off,” with fatigue, poor sleep, and irregular cycles. Her lab work came back normal, but her story fit perimenopause cleanly. That visit turned into the conversation she had actually needed, about what was happening in her body and what we could do about it.

Treatment follows the symptom pattern and the patient’s health profile. For hot flashes, hormone replacement therapy is the most effective option we have, though it is not right for everyone. Non-hormonal options including SSRIs and gabapentin also reduce vasomotor symptoms. Vaginal estrogen, as cream or tablets, works well for dryness and discomfort. Lifestyle changes carry real weight: a cool bedroom, less alcohol, regular exercise, stress management. Cutting caffeine after mid-afternoon sometimes does more than patients expect.

Preventive care deserves attention in this phase. Bone health matters more once estrogen declines, so I bring up calcium, vitamin D, and weight-bearing exercise. DEXA scans depend on age and risk factors. Cardiovascular risk climbs after menopause, which makes cholesterol, blood pressure, and diabetes screening worth staying current on. Breast and cervical cancer screening continue as appropriate. Colon cancer screening tends to land right in this age range as well, and over video I have to ask about it directly, because nobody volunteers that they are overdue.

Menopause is a normal stage of life that still manages to catch people off guard. Family physicians are well placed to normalize the conversation, take the symptoms seriously, and point patients toward both relief and prevention. Medication is not always part of that. Listening and practical support always are.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Does Chronic Stress Cause Weight Gain? A Doctor Explains

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Obesity gets described as a balance of diet and exercise, and stress plays a far larger role in it than most people are told. I have seen patients who eat well and stay active and still lose ground the moment their stress rises. Research from Dr. Rajita Sinha at Yale explains a good deal of why. Chronic stress produces measurable biological change, well past anything you would call a mood.

Stress acts on the brain circuits governing emotion, motivation, and self-control. Those circuits overlap with the ones handling food reward and craving, particularly for calorie-dense processed food (Sinha et al., 2022). Cortisol climbs under chronic stress. Ghrelin rises with it while leptin falls. What you end up with is a body primed to eat more, in an environment where high-calorie food is always within reach.

Calling that emotional eating undersells it. In Sinha’s lab work, people exposed to stress through guided imagery ate more snack food afterward, and participants who were already overweight were the most affected. Their cravings and calorie intake tracked with measured increases in cortisol and ghrelin. The stress reached past how they felt and changed how their brains and bodies handled food.

The pandemic ran this experiment at national scale. Nearly half of U.S. adults gained weight over that period, with worse effects among people who already had higher BMIs (Khubchandani et al., 2022). Children were not spared; CDC data showed the rate of BMI increase doubling against pre-pandemic years (Lange et al., 2021). The predictors of gain were emotional distress, having children at home, and how long it had been since someone last weighed themselves.

Work outside the pandemic points the same way. In one community study, people with higher baseline cortisol and greater insulin resistance were more likely to gain weight over the following six months (Chao et al., 2017). Those markers did more than correlate with obesity. They predicted it.

That has pushed researchers past the eat-less-move-more framing toward treatments aimed at the stress itself. Mindfulness-based stress reduction lowers food cravings, perceived stress, and blood pressure in people with obesity (Tuit et al., 2011). There is even evidence in parenting: a small study of low-income mothers found mindful parenting reduced parental stress and was associated with healthier BMI outcomes in their children (Jastreboff et al., 2018).

Medical and surgical treatment still matter, and the evidence suggests they perform best alongside strategies that reduce stress reactivity and support executive function. Stress management belongs in the treatment plan rather than tacked onto the end of it.

I have seen patients who feel defeated because they are certain the weight they gained under stress was a personal failure. The science says otherwise. Stress reshapes brain pathways, moves hormone levels, and changes eating behavior in ways we can measure. None of that makes change impossible. It does mean compassion is not optional in this conversation, and that treating stress as part of the disease moves the discussion off blame and onto something we can actually act on.

Scott Rennie, D.O.

References

Sinha R. Chronic Stress and Obesity. Yale School of Medicine, Columbia Obesity ABOM Virtual Course, 2022.

Chao A et al. High Cortisol and Insulin Resistance Predict Weight Gain. Obesity. 2017.

Khubchandani J et al. Depression and Anxiety Predict Weight Gain During the COVID-19 Pandemic. Diabetes & Metabolic Syndrome. 2022.

Lange SJ et al. Body Mass Index Increase in Children During COVID-19. MMWR Morb Mortal Wkly Rep. 2021.

Tuit K et al. Mindfulness and Stress Reduction in Obesity. Appetite. 2011.

Jastreboff AM et al. Mindful Parenting and Childhood Obesity Prevention. Journal of Pediatrics. 2018.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Envelope with stethoscope and graduation cap graphic and text congratulating Dr. Eliza J. Reed on her graduation

What Match Day Reveals About Doctors Choosing Family Medicine

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment
By Mary Forgione, Tribune Health – LA Times “Match Day” is a sort of March Madness for med students. It’s the time of year when seniors in medical schools throughout the country are matched with residency programs. Though the fine points of the process likely only matter to those craving a spot, the residency offerings do offer a glimpse of our future specialists, if not our general practitioners. The not-for-profit National Resident Matching Program on Thursday placed more than 16,000 U.S. medical students in a record 26,000 residency programs. The group reports an 11% rise over 2010 in the number of family medicine positions; seniors filled half the 2,708 slots available nationwide. Pediatrics and internal medicine are specialties that became more popular among students, as well as emergency medicine, anesthesiology and neurology. And here are some other trends noted in this statement: Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields for applicants. At least 90 percent of those positions were filled by U.S. medical school seniors. The number of U.S. medical school seniors in emergency medicine increased by 7 percent and grew for the sixth year in a row, as they filled 1,268 of the 1,607 first-year positions available. Anesthesiology offered 44 more positions and matched 45 more U.S. seniors who filled 671 positions of the 841 offered.” From the sounds of it, we need these new doctors because we could be facing a shortage. Here’s what this Los Angeles Times story says: “The Assn. of American Medical Colleges has warned of a deficiency of up to 125,000 doctors by 2025. And it isn’t the only group voicing concerns. The Health Resources and Services Administration, a federal agency that works to improve healthcare access for the uninsured, has projected that the supply of primary-care physicians will be adequate through 2020, at which point there will be a deficit of 65,560 physicians. The American Academy of Family Physicians estimates the need for almost 149,000 extra doctors by that year.” Now back to the people affected directly by Match Day. This Baltimore Sun story explains howone university, Johns Hopkins’ medical school, incorporated a St. Patrick’s Day vibe with the event: “They dipped their hands into the plastic pots at the end of a rainbow made of balloons. The coins they pulled out were made of cardboard but bore secrets more precious than gold. Where would they spend the next three to 10 years of their lives?”

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.