[ Meet a millennial family physician who is also a one-woman
antidote to private equity and the forces that have destroyed
compassionate treatment for patients.]
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MY LIFE IN CORPORATE MEDICINE  
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Stephanie Arnold, Maureen Tkacik
July 31, 2023
The American Prospect
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_ Meet a millennial family physician who is also a one-woman antidote
to private equity and the forces that have destroyed compassionate
treatment for patients. _

Stephanie Arnold, M.D., a family care doctor with her own practice in
Richmond, Virginia , Rebecca D’Angelo

 

_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
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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.

Expand
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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.

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* US Health Care; Private Equity Owned Health Care; Direct Primary
Care;
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