Category: Uncategorized

Episode 55: Sedera: A Health Plan for Small Businesses — with CEO Jamie Lagarde


  1. Sedera website
  2. Sedera pricing
  3. Sedera sharing guidelines
  4. Sedera video
  5. Jamie Lagarde Bio
  6. Jamie Lagarde LinkedIn Profile


For small businesses, paying for catastrophic coverage can be pricey if not outright unaffordable. Due to the unpredictability of insuring small numbers, businesses with less than 20 employees often get hit with high prices for health insurance premiums. As a result, many employees of such businesses go without benefits that may be afforded with a larger employer. Yet small businesses form the backbone of the US economy. For them to succeed, finding a way to insure their employees will be essential to the wellbeing of the country and future generations.

In comes Sedera Health Plan. Birthed out of a company devoted to supporting traditional, religious-based health sharing ministries, Sedera set out in 2014 to facilitate small businesses’ sharing medical needs with one another, regardless of religious orientation. Rooted in the philosophy that we can do better by sharing, and that if we all work towards a healthier lifestyle we can improve one another’s lot, Sedera works as a health sharing plan specifically for members of small businesses. Members pay approximately $150 to $200 per month to the plan, and in exchange, when they have a medical need, they receive FULL coverage of the need–regardless of network or location–above the initial unshareable amount, be it $500, $1000 or $1500. This allows members to get seamless coverage of health care needs without the hassle or cost of many major medical plans.

In the interview, Dr Roussel interviews CEO Jamie Lagarde about the Sedera Health Plan. He not only explores how the plan works, but how and why Sedera began, and how Sedera can be paired up with Direct Primary Care to provide members with seamless, affordable and satisfying health care.

Time Stamped

[2:57] What is the history of Sedera? Why was it founded and what is its mission?

[5:56] When a member has a need (e.g. cardiac catheterization, premature baby), can you walk me through how the sharing process works?

[9:07] Since Sedera is not a religious-based ministry, what are the requirements for a member to join?

[10:55] Does Sedera offer a discount for DPC membership?

[13:12] Do members of Sedra have to pay a penalty to the IRS?

[16:05] Does Sedera cover pre-existing conditions? If so, which ones and when?

[16:50] Does Sedera offer commissions to brokers?

CEO Jamie Lagarde


Mr Jamie Lagarde has nearly 2 decades experience in systems and operations. He currently serves on the Board of Directors for Goodwill in Texas. He has been the CEO of Sedera since their inception in 2014.


Related Episodes

Episode 13

Episode 14

Episode 54: Railroads: DPC & Fortune 500 Companies–with Dr Scott Conard


  1. Dr Scott Conard’s Bio (LinkedIn)
  2. Dr Conard’s Website
  3. Converging Health (Dr Conard’s company)
  4. Game of Health (Dr Conard’s other company)
  5. Holmes Murphy

Survey of DPC Podcast Intro Music


As it stands few patient’s of national/multinational companies have access to DPC as a covered benefit. Certainly, anyone within reasonable proximity to a DPC practice can individually enroll, but when many employees face wage stagnation and crippling premiums and deductibles, it would stand to reason that DPC would be a wise fit within the scope of their health care benefits. Yet at present, there are many barriers preventing DPC from  being a covered benefit for employees. From the company side, coordinating with multiple, heterogeneous practices across the country for a standard benefit package appears an insurmountable if not impossible challenge. Added to that, many brokers have been slow if not unwilling to adopt DPC given its novelty and (apparent) lack of direct commission for signing patients up for practice membership. From the practice side, many companies have been used to if not insistent on quality metrics provided by insurance companies or third party administrators to provide some sense of value for their health care dollars–real or imagined. Consequently, many DPC practices have been loathe if not unwilling to negotiate with companies asking them to essentially jump on the same bandwagon they just jumped off.

In this episode, Dr Scott Conard, family physician, concierge doctor and health care consultant, discusses how companies and DPC doctors can form new connections that could allow them to come to a mutually agreeable relationship. While not for every DPC doctor, Dr Conard emphasizes, railroads between large, Fortune 500 companies and DPC practices could give practices the fuel to grow with more certainty while allowing employers to provide employees high-quality primary care, lower their overall health care spend and improve the value of money they spend on benefits.

Time Stamped

[5:23] How Dr Conard went from being a solo family doctor to working with large employers?

[10:06] Dr Conard’s experience working in a high quality primary care practice that shut down its cost saving measures when bought by the hospital.

[13:37] What are some of the challenges from the company stand point when working with DPC doctors?

[20:02] From the doctor standpoint, what are some of the challenges DPC doctors have when exploring a partnership with large companies?

[24:22] How can a DPC practice work with third parties and not get taken advantage of by middle men?

Dr Scott Conard


Dr Scott Conard is a family physician and health care consultant. He started his career as a family doctor in Irving, TX, eventually growing his practice to 13 doctors. He then started a health literacy program for corporations called the Game of Health, which led to him serving as the Chief Medical Officer for Holmes Murphy. He now serves as a concierge physician and consults with large companies on how to improve the health of their workforce and how to improve the value of their health care.


Related Episodes

Episode 1

Episode 35

Episode 36

Episode 37

Episode 38

Episode 40

Episode 44

Episode 45


Episode 53: The DPC Summit (2018) Recap with Dr Staci Benson

“Revolutions are bloody, and that’s what this is. Direct Primary Care is in the middle of a revolution.”
–Dr Erika Bliss, Former CEO, Qliance


  1. 2018 DPC Summit Agenda
  2. DPC Program Guide
  3. DPC Summit Presentations
  4. DPC Summit Speaker Bios

The Direct Primary Care Summit is arguably the largest gathering of DPC doctors from around the country. Every year DPC doctors convene to learn more about DPC and grow the movement to restore health care. The 2018 DPC Summit was held in Indianapolis, IN from July 13-15. The summit featured a number of motivating, informative and inspiring talks from DPC doctors and community leaders from around the nation. In this Episode Dr Staci Benson, DPC Summit steering committee member, founder of Paradigm Family Health and DPC grassroots organizer, gives a brief summary of each of the talks from the DPC Summit. For each talk she not only gives a brief synopsis of the content but also the importance of each talk to the overall growth of the movement.

Time Stamped
[4:30] In “Take a Leap of Truth” Jeff Gold, MD talks about the meaning of “Salveo,” and its importance to his work as a DPC doctor.

[6:02] In “Prove It or Lose It: Defining Outcomes the DPC Way” Joel Bessmer, MD talks about the importance of defining outcomes to prove to payors the efficacy of DPC and how Strada has been able to do this with nearly no additional effort on part of providers.

[8:19] In “DPC as the Advanced Alternative Payment Model — National Update” Brian Forrest, MD talks about the success of the Transforming Clinical Practice Initiative pilot
[10:14] In “If You’ve Seen One DPC Practice, You’ve Seen One DPC Practice” Thomas White, MD (Moderator); Cory Annis, MD; Maura McLaughlin, MD; Kylie Vannaman, MD talk about the uniqueness of each DPC practice and how doctors are able to individualize their practices

[11:15] In “Working With Small Employers: Creating Healthy Employees and Happy Employers’ Risheet Patel, MD, and Brad Banks, Co-Owner of Banks and Brower, LLC talk about how DPC as a covered benefit has helped improve employee and employer satisfaction

[12:25] In “Tunneling Through the Rock: The Qliance Experience” Erika Bliss, MD delivers a candid talk about the rise and fall of Qliance, expressing hope and optimism for DPC

[13:40] In “Lines in the Sand: Boundaries and Sustainable DPC” Julie Gunther, MD, and Delicia Haynes, MD talk about the importance of boundary setting when offering “24/7 access”

[14:47] In “Pearls of Wisdom for DPC Practices — What Works and What Doesn’t” Brian Forrest, MD and Emilie Scott, MD talk about the importance of keeping the DPC set-up simple and straightforward

[16:06] In “DPC Advocacy Briefing” Staci Benson, DO and Jay Keese give an update on the current status of the “Primary Care Enhancement Act”

[17:37] In “DPC Changed the Rules; Reclaim Full-Scope Practice!” Vance Lassey, MD, and Nick Tomsen, MD talk about how DPC has allowed them to reclaim full scope of practice, including maternity and in-patient care

[18:44] In “Employers & DPC: How-to Guide” Chris Larson, DO talks about how his practice has been able to pair DPC with wrap-around coverage to lower cost and improve value

[19:43] In “DPC Hustles Harder” Paul Thomas, MD talks about the importance of branding and social media presence for DPC practices

[20:30] In “Pressure and Fire” Julie Gunther, MD talks about the impact that pressure has had on her character, ultimately helping her grow as a person from the experience of being a DPC doctor

Dr Staci Benson


Dr Staci Benson is a family doctor from Dallas, Texas. She is the founder and owner of Paradigm Family Health. Among many accomplishments, she is an experienced grassroots organizer and has been instrumental in promoting the DPC movement.


Related Episodes

Episode 33

Episode 41

Episode 42

Episode 44

Episode 52: HSA Bill Update & ‘Why I Do DPC?’–with Dr Phil Eskew & Docs from the DPC Summit


  1. House Ways and Means Committee Vote Update (Dr Phil’s Blog Post)
  2. HR 6317 Text
  3. Video of Markup from Ways and Means Website
  4. Direct Primary Care Coalition Update on the Markup

Survey on New Intro Music for the DPC Podcast


At present it is technically not legal for patients to use their HSAs to pay for direct primary care, but a bill to change this has been years in the making. This direct primary care and HSA bill, known as the Primary Care Enhancement Act (Formerly HR365, now HR6317), was just marked up through the Joint Committee on Taxation and passed the House Ways and Means Committee. In the process, the bill’s original text was changed to include some new provisions, including a $150 cap of the monthly fee. In this episode, Dr Phil Eskew, legal expert and DPC doctor, discusses what the changes mean for direct primary care practices and what lies ahead for the bill to become law.

As well in this episode, Dr Roussel interviews Dr Yusuf Mathai (Sherwood, OR), Dr Claudia Emmons (Ocala, FL) and Dr Chris Larson (Austin, TX) from the DPC Podcast booth at the DPC Summit about why they chose DPC.

Time Stamped
[4:08] What’s happened in the past couple of weeks in the direct primary care and HSA bill?

[4:55] Why the Joint Committee on Taxation wanted to change the bill?

[5:12] What are the changes made to HR 365 (now HR 6317)? Why they made them?

[7:14] What happens after a House vote to HR 6317 for the bill to become law?

[9:44] Why Dr Yusuf Mathai decided to start a DPC Practice?

[10:48] Why Dr Claudia Emmons decided to switch from fee-for-service to DPC?

[12:37] Why Dr Christopher Larson went into DPC?


Dr Phil Eskew

Dr Phil Eskew, DO, MBA, JD is a DPC doctor. He is also of chief legal counsel at ProactivMD and the DPC Coalition and is recognized as the pre-eminent legal expert on DPC and the law.

Dr Yusuf Mathai

Dr Yusuf Mathai is a family physician from Oregon who has chosen to embark on DPC after 7-8 years of practice in fee-for-service medicine.

Dr Claudia Emmons

Dr Claudia Emmons is an internal medicine physician from Ocala, FL who decided to switch her practice over to a DPC practice after running an insurance based practice for several years.


Dr Chris Larson

Dr Chris Larson is a family physician from Austin, TX who started a DPC practice as a physician after switching to medicine from a finance career.


Related Episodes

Episode 4

Episode 51: Bringing Clarity in this Dysfunctional Industry…with Mr Richard Brewer


  1. Paragon  Benefits
  2. What is a Third Party Administrator? (Blog Post by a DPC Practice)
  3. Understanding Self-Funded, Fully Insured Employers (Spruce Blog Post)

Few would argue that healthcare administration today is a dysfunctional industry. Incentives are misaligned and consequently cost does not translate to value. Employers and consumers get the short end of the stick. Direct primary care changes this by restoring the doctor patient relationship and eliminating excessive third party oversight. Still, however, patient’s need insurance for needs that can not be met by a DPC practice. In comes the need for employer self-funded plans, and Paragon Benefits, a third party administrator in Georgia, offers just this–employer self-funded plans that customize coverage to the needs of the employer. As a consequence, given that these plans are customized, they allow the employer save money that would otherwise go to a middle-man. What’s more, Paragon’s plans can be customized to pair up with DPC and cut-out the premium inflation that would go to low value primary care under a fee-for-service plan.

Time Stamped
[2:31] So Mr Brewer can you tell me a little about the history of Paragon?

[3:08] Changes to third party administrator companies under the Affordable Care Act?

[3:58] The motto of the company is “bringing clarity in this dysfunctional industry.” Why is that?

[5:35] Size of employers that Paragon specializes in.

[6:51] How many lives are covered on Paragon plans?

[7:47] What are the main geographic areas you serve?

[8:05] What networks do you use? How many of your plans are reference based?

[10:26] How can an employer/DPC doctor pair together to work with Paragon?


Mr Richard Brewer is a chief sales representative for Paragon Benefits. He has 20 years of experience in healthcare benefits administration.


Related Episodes

Episode 15

Episode 16

Episode 36

Episode 37

Episode 38

Episode 48

Episode 50

Episode 50 MyMDConnect’s DPC-Based Insurance Plan–with Dr Jeremy Smith


  1. MyMDConnect

One of the biggest challenges Direct Primary Care doctors have faced in getting their model to grow is finding compatible insurance plans for their patients. Many employers, for instance, love the convenience and value of DPC practice membership for employees but the cost often does not translate to reduced payments on insurance premiums. That is, until companies like MyMDConnect have come along. They offer self funded insurance plans that specifically pair with DPC practice membership.

Dr Jeremy Smith, a family doctor from Northeast Texas, founded MyMDConnect as a solution to employers who sought health insurance plans that save money and provide value. Partnering with an insurance agent who was as fed up with fee-for-service health care as he was, he started a plan that integrates all of the necessary components of a self funded insurance policy. This plan, moreover, often saves 40-60% compared to traditional major medical because of the cost savings that DPC membership offers–not only in terms of reduced cost for doctors visits but also because of less ER visits, hospitalizations, specialist visits and duplicate testing.

MyMDConnect has signed up businesses throughout the Southeastern US and is rapidly growing as employers seek innovative alternatives to bureaucracy-laden, valueless traditional health plans. In the interview Dr Smith talks about how he got into DPC, how he came up with the idea of a DPC-Based insurance plan and how other doctors can join MyMDConnect and offer low-cost, high-value insurance plans to their DPC practice members.

[3:30] Can you tell us about the history of MyMD connect. How did you get into the employer self funded insurance market?

[11:27] Can you explain how the plan works?

[14:46] What is the minimum employer size?

[17:14] What geographic areas does MyMD connect serve?

[18:32] What plans can MyMD connect offer if there is no DPC available?

[19:24] How many covered lives do you have under MyMD connect plans?

[20:36] How can a DPC doctor or employer or broker get a hold of you?

Dr Jeremy Smith


Dr Smith is a family doctor who has a DPC practice in Nacogdoches, TX. He started MyMDConnect as a way to offer employers a comprehensive self-insurance plan to pair with DPC.


Related Episodes

Episode 15

Episode 36

Episode 51 (coming)

Episode 49: Behind the Scenes & A Look Ahead–with Mr Jeff Blackwell

Episode 49: Behind the Scenes
There is much more to a podcast than what the ear can hear. The work that goes on behind the scenes is often not seen or talked about for many podcasts. Much less does a listener learn who is the audio editor or what he or she has to do with the show. In this episode, Dr Roussel talks with Mr Jeff Blackwell, the editor of the DPC Podcast about the work that goes on behind the scenes. In it they talk about the work done to craft the DPC message for every show. Mr Jeff moreover describes his passion for radio and how his and Dr Roussel’s paths crossed to lead to a fruitful collaboration in making a disruptive health care podcast.

Time Stamped (times on the way)
First of all, starting next episode on Thursday, we’re going to stick to a more regular schedule of posting Tuesdays and Thursdays at 530am CT/630AM ET.
As well, we’re going to put any Q&As at the beginning of the show and we’ll do our best to limit this to 1-2 minutes. Quick responses to listener-submitted questions.
As far as the topics ahead, here’s what we have in store for our show topics:

  1. For the next couple of episodes we’re going to be wrapping up our discussions from the Hint Summit with Dr Jeremy Smith of MyMD Connect about the employer reference-based insurance plan he’s started that is purely DPC focused and with Mr Richard Brewer of Paragon Benefits, a third party administrator  which offers reference based insurance plans that pair with dpc.
  2. For the next few episodes we’re going to be talking to hosts other health care podcast hosts
  3. Then Marketing your DPC practice
  4. Then DPC friendly EHRs and apps
  5. Then exploring some health coaching options within DPC
  6. Then holistic and alternative medicine within DPC
  7. Finally Medical Education and DPC–talking with residency PD’s and medical school faculty about promoting primary care through DPC

So Jeff, take it away, what does go on behind the scenes at the DPC Podcast?
Something I haven’t asked you before, what got you interested in audio & radio as a career?
Interesting story of how we met…
Now, you’ve learned a thing or two about DPC and doing a health care podcast…

Mr Jeff Blackwell

Mr Jeff Blackwell has been in radio and broadcasting for over 40 years and has worked as a live audio engineer for ESPN, Fox Sports at the US Olympic trials as well as a voice engineer for Scooby Doo and many more. Also a lesser known fact about Mr Jeff, he’s been designated by some Louisana Tourist Centers as the best “Voice of God” voice in the Baton Rouge area.

Episode 48: How to Pick a Benefits Broker–with Mr David Contorno

David Contorno is a one-of-a-kind benefits broker. What’s more, he’s leading the nation in a reform from old ways of doing business to new, innovative value based solutions. For Mr David, moreover, value is not some gimmick slapped on top of a plan to appease a client or some lip service done in the name of more business, it really is value. How do we know? He’s put his money where his mouth is. As a successful young agent, he cut out major carriers that were offering hundreds of thousands of dollars in commissions and went directly to his clients to negotiate a fair commission to work truly on their behalf.

In the interview, Mr David talks about the perverse financial incentives that keep brokers going back to major carriers, even though their health insurance plans often provide little value in return. He moreover elaborates on how he personally came to realize that these plans were not in the best interest of his clients and how he cut out those carriers to go directly to employers and provide them the plans they need. By pairing Direct Primary Care with self-funded plans, Mr Contorno has been able to save employers a minimum of 24% on their overall healthcare expenses and on average well over 40%, with a much higher satisfaction from his clients.


[1:51] So, in your chapter “How to pick a benefits consultant,” you point out perverse broker incentives that contribute to a wasteful status quo. Why is this and how did we get here?

[4:23] Why have benefits brokers been so reluctant to venture into employer self-insurance?

[6:27] How does self-insurance save companies money?

[6:58]  For an interested broker, where can he/she start if he wants to set up an employee self insurance plan to say pair up with DPC?

[8:57] How interested brokers can learn more?

Mr David Contorno

Mr David Contorno is one of America’s leading benefits brokers. He has been brokering insurance plans since the age of 14 and founded Lake Norman Benefits in his 20s. He now works as a benefits broker for the Hilb Group and focuses on educating other benefits brokers to provide high-value plans through the Health Rosetta project.

Episode 47: The CEO’s Guide to Lowering Cost, Improving Value–with Mr Dave Chase

“The deeper I got into analyzing the healthcare system, the more I realized that it’s the most immediate threat to America.”
–Mr Dave Chase


  1. Dave Chase LinkedIn Profile
  2. “The CEO’s Guide to Restoring the American Dream” — Link to Free Download of Dave’s Book
  3. Health Rosetta
  4. Forbes Articles by Dave Chase
  5. TedTalk by Dave Chase


As of this writing, most US-based companies are hemorrhaging money into healthcare and getting little value in return. Sadly, less than 20% of dollars spent on healthcare by companies actually goes to doctors who provide high-value care. The rest goes to pay for fraud, administrative overhead and other wasteful ventures. As Mr Dave Chase notes, we are not chained to the status quo. For the CEO or executive who wants to save money and improve value on their healthcare dollars, they can provide better benefits for less by making some simple changes. In the interview, Mr Dave Chase, author of “The CEO’s Guide to Restoring the American Dream,” founder of the Health Rosetta Eco-System, regular Forbes author and successful healthcare startup entrepreneur, talks about the solution for companies to “get it right” with healthcare.

Dave has offered a free download of the book we discussed — CEO’s Guide to Restoring the American Dream (follow the link for the download). You can learn about how under-performing health plans have caused great harm to America but how organizations are proving how straightforward it is to fix.

Time Stamped

[2:24] So what was your inspiration behind writing the “CEO’s Guide to Restoring the American Dream”?

[3:33] In part I of the book, “The Current Situation,” you talk about the current financial crisis we’re facing in healtchare expenditures. Can you give us an overview of why companies are hemorrhaging so much money on healthcare and getting so little in return?

[6:02] To “get it right” you talk about getting it right with benefits consultants, yet many consultants are stuck with the broker/dealer/peddler relationship with little interest in changing the status quo and providing value. Where can a company start to “get it right?”

[7:25] If you were to give one piece of advice to a CEO or company executive when it comes to lowering costs and increasing value of their employees’ healthcare, what would it be?

Mr Dave Chase


Mr Dave Chase is a successful entrepreneur, speaker and author. He has founded two $1 billion companies within Microsoft, and co-founded a healthcare startup Avado that was eventually acquired by WebMD. He is the author of “The CEO’s Guide to Restoring the American Dream,” numerous Forbes articles and co-author/co-founder of the Health Rosetta Eco-System. In addition to his many professional ventures, Mr Chase is a father, husband and an avid mountain sport athlete.

Related Episodes

Episode 1

Episode 35

Episode 36

Episode 37

Episode 38

Episode 40

Episode 44

Episode 45

Episode 46: Q&A: The Elephant & Rider Analogy: Does it Work for DPC?


What I love about DPC is that we are doing just that, keeping the beauty of being a primary care doctor present while adopting the modern technology and innovations of the 21st century to help make our lives happier, healthier and hopefully a little bit wiser.

–Dr Roussel



Many metaphors have been used to describe institutional stagnation. When a social institution such as healthcare fails to live up to society’s expectations, the impulse to understand why the institution is failing is certainly reasonable. One such metaphor used to describe the failure of our healthcare system has been the elephant and rider analogy. In particular this elephant and rider metaphor has been used to apply to direct primary care. The mind, so goes the metaphor, is like an elephant and a rider. Our choices on the one hand come from a rational rider who seeks to guide the elephant, while on the other hand they come from the elephant within us–irrational forces that guide our behavior despite our attempts at rational control of ourselves.


In this episode, Dr Roussel elaborates on the metaphor’s application to Direct Primary Care. “Does it work for DPC?” he asks, and if it doesn’t, what’s a better alternative?


Time Stamped


[1:26] As the DPC movement continues to grow, one of the issues we’ve come up against is institutional changes. What does it take to change a system where perverse incentives discourage making a positive change?


[1:41] An analogy that’s been used to describe the situation is one that was originally introduced by psychologist Jonathan Haidt in the Happiness Hypothesis, elaborated on in “The Righteous Mind.” It’s been used by many other writers, other particular notable writers are the Heath Brothers & their book “Switch” about challenges with institutional change. The idea goes that we are all led by unconscious behaviors as a result of millions of years of evolutionary forces, creating our lower brain, our limbic system, I might even add autonomic nervous system and brain stem to that. This is the elephant in the analogy. We also have a neocortex, the reasoning, planning part of our brains. This is the rider


[2:30] The prevailing paradigm for the past couple of centuries really has been that we as humans will always make rational, reasonable choices. When in reality, say supporters of the elephant rider hypothesis, we are all led by the elephant. The unconscious thoughts, impulses, that stem from our primitive history.


[3:03] If we can all better understand this, we can be better riders of the elephant. We can live in harmony with the elephant, be aware of the effect of environment on the elephant, how learned behaviors don’t change quickly, how fight or flight can keep us from working together, etc. For healthcare, goes the analogy, if we can recognize the perverse forces encouraging doctors, healthcare workers, brokers, insurance companies to act in a way that does not benefit the system, that forces us to continue this dog-eat-dog way of behavior in the healthcare market, then we can start to change those forces, bring the elephant into the Savannah with lush green grass, water and all live in harmony.


[3:51] Now I’m simplifying the model but the basic idea is that that awareness of those forces–of our primitive impulse–can help us address the systemic issues at hand. To be clear, I’m certainly a supporter of mindfulness of systemic forces, and I love metaphor and I do like this analogy.


[4:23] I do think it’s important to point out some challenges when applying the elephant rider analogy to healthcare. That’s what I want to talk about. This is deep, and theoretical, I know, so I’m not offended if this episode is not your cup of tea, but I think discussing the purpose and the meaning of DPC is important to a movement that many of us believe is formed out of value, meaning and conviction.


[4:52] To start, one of my most influential classes in college was called ‘Civilization and Barbarism’ and the course focused on Shakespeare’s play The Tempest. In particular, we focused much of our attention, for the class, on the character Caliban, who has sort of a quasi-human almost animal character, with poor control of his appetite and ‘uncivilized’ behavior. The point of the class was to show that at the outset, to many literary critics contemporary to Shakespeare Caliban represented the European vision of the uncivilized native. On deeper inspection, the metaphor of Caliban can be equally applied to Western colonial powers whose attempt to ‘civilize’ the world actually represented an attempt to institutionalize their own primitive impulses. Now historically this is only partially true, but in any case the point is that awareness and mindfulness can serve as its own barrier to institutional change.


[5:57] The birth of the ascetics and many other derivative schools of the late Roman empire saw mindfulness not as a tool for social change but as a path to avoid the painful realities of a chaotic, fading civilization. The idea wasn’t to change the world but reach such a state of mindfulness that the outside world didn’t matter anymore. I point this out not to minimize the importance of the metaphor or of mindfulness but to bring up a couple of important caveats when thinking about institutional change:


  1. [06:31] There may be sinister forces at play with regards to resistance to change in healthcare. Some may indeed want to preserve the status quo simply because it keeps their company, making more profit than without the status quo–even if such a resistance comes at the expense of everyone’s wellbeing. That shouldn’t stop change from being pushed.
  2. [06:58] More importantly, pictoralizing the elephant and rider as two separate entities does encourage a mind-body sort of mentality that can be a slippery slope to the same sort of issues that started our institutional problems in the first place. Much of the over technicalization of medicine can be traced to a set of education reforms in the 1920s called the Flexner reforms, where the US DOE attempted to standardize medical education as an attempt to–to use our analogy–increase control of the rider over the elephant–to root out our uncivilized, basest instincts and encourage a more rigorous, scientifically-based medical education. This undoubtedly led to an over-technicalized medical education that in no small part contributed to over-specialization of the profession and even the CPT based coding system we now have that has made primary care so unpopular.


[08:09] To put it simply, I’m loathe to accept rational control of the subconscious mind as a path forward.


[08:18] So what does this mean?


  1. [08:23] I think it’s important to remember that Hippocrates in many ways is still a model for the profession. For Hippocrates medicine was a process on the one hand, with a history, physical, diagnosis and exam, but it was also an art. The process of phronesis I think describes clinical judgment beautifully. Not quite a technical procedure, rather an art of bringing together experience, art, science and knowledge. The point of the a good judgment was to help the doctor and patient reach a state of happiness, Aristotle called it eudaimonia, a balance of mind and body and society, a harmony worked towards though never quite fully achieved. I would consider this a much more unified view of the elephant and rider than a simple bottom and top, rider and elephant analogy.
  2. [09:23] The profession is in a constant state of flux with society where old habits are being thrown away, but it’s always important to discern what needs to be kept from what needs to be left behind. As we move from metaphors of health 1.0, 2.0, 3.0 etc, I think it’s important to figure out what was beautiful and good about being the docs that ‘our grandmother used to have’ from that which was wasteful and even harmful about that same system.


[09:56] What I love about DPC is that we are doing just that, keeping the beauty of being a primary care doctor present while adopting the modern technology and innovations of the 21st century to help make our lives happier, healthier and hopefully a little bit wiser.

Related Episodes

Episode 1

Episode 34