On this episode of the podcast, we kick off our New Models Series with guest Dr. David Tusek. Dr. Tusek built the first direct primary care clinic in Colorado and now operates a world-class facility called Cloud Medical. In this episode, he shares his insight on creating and building a direct primary care practice.

Highlights include:

  • Dr. Tusek’s journey to functional medicine and how he created his own direct primary care practice
  • A deep dive into the 10 Heartbreaks of Medicine
  • Dr. Tusek’s eBook: Salutogenic Eudaimonics
  • And so much more!

Resources mentioned in this episode:

New Models #1: Solving the 10 Heartbreaks in Medicine

James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs in health technology, as well as practical tools to help you transform your practice and the health of your community. This podcast is brought to you by the Lifestyle Matrix Resource Center, who provide a range of options to help you deliver successful, effective, functional, and integrative medicine. To find out more and to get started, go to goevomed.com/lmrc. That’s goevomed.com/lmrc.

Hello and welcome to the podcast. This week, we are starting our new series. We are looking at new models for medicine. In this year of reinvention, nothing could be more important than looking at the new models that will reinvent medicine. I’m super excited to bring on the show Dr. David Tusek to kick off this year.

Dr. Tusek built the first direct primary care clinic in Colorado. He now has a world-class facility called Cloud Medical, with over three locations in Boulder County, Colorado and has been a very clear thing on what it’s going to take to turn medicine around. This podcast is a bit longer than ones that we’ve done before. But it is absolutely jam-packed with the heart of what we’ve been trying to do at the Evolution of Medicine here for more than eight years.

Now, we’ll be talking about the 10 heartbreaks of medicine and accompanying this podcast is an ebook that he created called Salutogenic Eudaimonics and why it’s called that will become clear very soon. Perfect way to kick off this season. Enjoy. So a warm welcome to the podcast, Dr. David Tusek, welcome, Doc.

David Tusek: Thank you so much, my friend. Thanks for having me on.

James Maskell: I’m super excited to have you here not just because I’ve wanted to have you on the podcast for so long, but just kicking off our Year of Reinvention on this new podcast series, that’s going to be on the new models. It seems like the perfect place for this to land. So just so the audience knows, you and I met after the Knew Vision Tour Stop in Boulder and we’ve been really engaged since then in working on a relationship and understanding what you’re up to and how we can best work together.

I’d like for everyone who’s never heard of either you or Cloud Medical, which is your medical practice, just to share a little bit of the history of your own journey to thinking about holistic medicine and then also to arriving at Cloud Medical.

David Tusek: Yeah. Well, I think a great place to start is just to really back it up. I want to start by saying that I really think that we are within reach and within grasp of a true primary care renaissance that is only just getting started with the different evolutions that you’ve been a big part of, James. Evolutions like direct primary care and functional medicine, which are also foundational elements of Cloud Medical and a lot of the work that I do.

I think that if we seize the opportunity for that renaissance, truly and fully, it’s going to happen right on time, it’s going to be very welcome and it’s by no means a done deal. There’s a lot of work to do, but I think we have everything that we need to pull it off, the capability, the workforce and the brain power.

Obviously, we’re in the midst of very turbulent times. A lot of tectonic plates are sort of shifting underneath our feet in all ways and there’s uncertainty and fear and anxiety about everything. I think it’s in these times, these kinds of times that you sort of have to ask these big centering questions like what does the world need? What is mine to do? How can I be most helpful? I think that those are exactly the kinds of questions that I’ve been asking and you’ve been asking and so many of your listeners are in the process of asking and defining for themselves really and not just in the here and now, not just in the present moment, but really what can we do as in the context of the much longer view of this trajectory.

The context of how can I be a worthy ancestor for those that come after. Not just as individuals, not just me, what can I do, but what can we do, as a profession, as a guild as a specialty, as primary care specialty in medicine, in fellowship and solidarity. If we are to envision this primary care renaissance, that we can sort of begin to see began to really feel into what would that look like to fully embrace it.

I think that what that looks like and where all of this work stems from is that we have to reclaim our sovereignty. We have to reclaim the power to decide what matters most in our work. Unfortunately, within the mainstream and the conventional system, its current flow, we’ve allowed those things to be completely delegated. Not to other clinicians or other doctors or healers or other people involved in patient care, but to those parties that have nothing to do with any of those things.

And so again, from my perspective, in doing so, what we’ve allowed to happen is our fundamental core value, our most sacred sort of guiding principle, we’ve let slide. The most important thing about our field, about our profession, I believe we’ve all but lost and then we’ve also kind of swallowed this big lie, this huge myth that I think has led our profession astray. It’s kind of a big and long winded answer to your question, but just the context, I think that if we’re going to really take these reins and rise to this historic occasion and usher in this primary care renaissance, which I believe many of us are in the process of doing or participating in our own small ways, I feel that I am trying to do that in my small and humble way, then we’ll be able to provide a huge value and clarity in leadership and reassurance and a clear path forward in these very confusing times.

Those are maybe some big words or big concepts, but what’s this core value that I feel has been eroded and the most important thing that we’ve lost and the myths that we’ve kind of come to believe? We can maybe use those to frame the rest of the conversation. I think we have to come back to the core value of a reverent devotion to our patients’ best interests.

I think that’s it. That is the singular loyalty and allegiance that we have to align ourselves with and in the conventional system out there, that’s becoming harder and harder to do and it’s becoming more and more eroded. I think the missing element that we’ve lost that we need to recapture is that we’ve really let go the concept of health. We’ve focused almost exclusively on sick care and disease management and pharmacotherapeutic treatments. And we’ve really need to reclaim this whole concept and idea of what it means to be healthy and what it means to heal and complement that, not discard our knowledge of the origins of disease but also complement that with a deep knowledge of health.

And that term, the etymological root of the word health comes from this dual connotation of wholeness and holiness. There’s something about the meaning of health that speaks to that which is sacred about life and about being alive, as well as this notion of becoming a whole and integrated human being. That’s the missing element. And then the core lie or almost like the original sin, I feel that that has made us take this wrong turn and that we need to really correct and redirect is this notion that we need to maintain a separation. We need to maintain a distance between the doctor and the patient.

Because if we get too close, we’re going to suffer if our patients don’t do well. Or if we get too close, we’re going to lose our scientific objectivity and our rational objectivity, that’s going to Cloud our judgment. I think this is a profound lie. I think this is something that we have taken at face value and accepted without really challenging it. I think it needs to be challenged and the therapeutic human connection and the attunement that happens between two human beings that comes from a deep well of caring and quite frankly love is part of the reason these three things together, this core value, this lack of connection and this missing attention to the deeper meaning of health, these three things have led to our sort of lost compass.

We’ve lost our sovereignty as clinicians, healers and doctors and we’re suffering deeply from horrific levels of burnout. Now I saw on Netscape recently that physicians are the number-one profession now for suicide. And so this whole journey, for me has been a slow gradual and methodical kind of attempt to be as intellectually honest and as intellectually precise as I can be about what’s good in medicine and what needs to be preserved.

There’s so much that we should be grateful for and we need to celebrate that’s going really, really, incredibly well. There’s true and real miracles and marvels of modern medicine. We can talk about those specific things. I think we need to be clear about what’s missing, what needs to be added as we just mentioned and then what’s not working. Like what’s really not working on a deep and fundamental level that needs to be changed or discarded. I think that we have to do this ordering and reckoning but we have to do it in an even broader context. So there’s so much that I think in primary care needs to be really scrutinized and looked at.

Personally, I don’t think it’s too strong of a term, to use, to say that we are totally and completely in the midst of an existential crisis. People are calling into question the very relevance of our specialty. They’re saying, “Why the hell do I need a primary care doctor? If I have a heart problem, can’t I see a cardiologist? If my knee hurts, why can’t I see an orthopedist?” We haven’t done a good job of answering that question.

You could call it the marquee event of primary care medicine, the annual physical exam, the HMP, the history and physical. Even back 20 years ago, the New York Times was calling it an empty ritual. The New England Journal, a few years ago, called it a total waste of time and money. And then there was an article that is worth reading, like us, in the primary care fields, we should be reading these critiques. In Wired Magazine, this was in May of 2020, article that called the annual physical absurd. It’s absurd. Like a 40-year-old coming in asking to turn his head and cough just didn’t even fit.

People were like…well, biotech is supposedly outpacing Moore’s Law. How is it possible that the annual checkup hasn’t changed in 40 or 50 years? It just doesn’t make any sense. Trust has been eroded. That’s another big area that has gotten a lot of attention. There was an article just in December of JAMA, talked about the erosion of trust. That was in healthcare system in general, but I think it applies very specifically to primary care medicine where in the 1960s, I think it was 78% or 75% of Americans had a deep sense of trust in their physicians, whereas now it’s somewhere in the 30% range. That’s why you have all of these different entities. You have Walmart, you have CVS lining up and saying, “Primary care? We can do that. We can do that. We’ll just put up a mini clinic in our grocery store and that’ll be primary care.”

And so, I think our access, our accessibility…the average wait time for a primary care appointment is something like three to four weeks. In some geographies in America, it’s six to eight weeks or after hours, availability is nonexistent. It’s urgent care or ER. When you do get an appointment, it’s a seven- or an 11-minute perfunctory visit.

That’s all about band-aids and quick fixes. It’s one problem at a time. If you have more than one problem, you have to make another appointment. Underlying all of this is this profound and deep onerous petulant, I would even use the word metastatic growth of administrative burden of busy work and onerous time consuming tasks on already totally overburdened primary care physicians that is only continuing to get worse to the point that…

It’s just staggering. We are now spending $3.3 billion per day, per day on non-clinical healthcare administration. I think we’ve all seen this crazy map or this crazy graph, excuse me, of the growth of dollars that went to pay physicians’ salaries over time compared to dollars that went to administration. The physician salaries are all but flat and the administrative growth and cost has gone up. I think it’s 3,300% since 1970. These are just some of the issues that we’re facing that we all are wrestling with in so many different ways and we’re trying to find a path through the trees. I just want to quickly say that it’s important to also see them in context.

So primary care and again, I believe that we have this existential crisis that I laid out, is nested within a larger obviously healthcare system. That of its own is undergoing a crisis on multiple levels, a crisis of solvency, a crisis of financial sustainability. We’re spending…in 2019, this was before COVID, the entire US government budget was 3.4 trillion and we spent 3.8 trillion on healthcare.

By 2027, that’s five or six years from now, that number is going to be 6 trillion. We just can’t make the math work anymore. David Chase, who I think we both know is a fantastic thinker and commentator about what’s going well and what’s not going well in medicine was published in Forbes Magazine and his statistic was that millennials, the millennial generation, our kids are going to be spending two thirds of their life earnings on healthcare.

That’s just the cost. The healthcare system and I’ve kind of written about this, I call it my 10 heartbreaks, which is the multiplicitous crisis that’s happening within the healthcare system. We can talk about some of those, but that healthcare system is also nested within a larger context, which is the sociocultural container. And that is also undergoing its own series of crises. Some people call it the meta-crisis. I’ve sort of laid out into four different major criteria. This is a, I think, an important vantage point or perspective or point of view to take is, well, these are all interrelated, interdependent, nested issues that I think it’s important to tease them apart, but also see how they are coherently connected because they’re all very, very important and you can’t fix one without the others.

Primary care is a big piece of the healthcare system. By some estimates, 90% of all health care encounters occur in primary care. So that’s a big chunk. The health care system is a big chunk of this larger socioeconomic or sociocultural container. It’s somewhere between a quarter and a third of our entire economy.

We need to begin, this is where I think the sort of the mind space of a generalist, by definition, a generalist thinker like a primary care physician is useful because we’re not focused on a toenail or a single organ, we’re focused on the whole ideally. And I think that we have a huge number of things to begin to sort through but without seeing how they’re all interrelated, we’re going to have difficulties moving forward and I think rising to this great occasion that we’re at the precipice of which is a real and true primary care renaissance.

James Maskell: Absolutely. Look, I want to share, first of all, I know that for a lot of people listening to this, they’ll have a deep resonance with what you just shared. And I wanted to just let you go at it. Because ultimately, I think part of the reason why maybe doctors are ending up committing suicide at that level is that they realize how deep the crisis is and how broad it is and how…it makes its way into all parts of our lives, never mind just medicine. So I want to share my appreciation for just sharing that.

I also want to share with everyone that along with this podcast, I want to share one of the most profound assets that I’ve seen in the last year, which is your ebook called Salutogenic Eudaimonics, which we’re going to get into here in a minute. And that ebook is available. If you go to the show notes, you can download it, it’s free. You can check it out. It’s not very many pages, but it really clearly articulates some of what has already been articulated.

I want to get into these 10 heartbreaks of medicine, but before we do, let’s just talk about the name. So Salutogenic Eudaimonics, I know that for a lot of people my second book really introduced this idea of salutogenesis to people had not heard that term before. And eudaimonics is certainly something that was new to me and I’d love for you to explain those two words, why they’re important in this reinvention of primary care, why they go so well together and why those two words are the name for your treaties on this reinvention of primary care.

David Tusek: Yeah, thank you. Salutogenetics or salutogenesis comes from the work of a brilliant man who was a sociologist and psychologist in New York, after World War II, who was fascinated by studying Holocaust survivors. His name was Aaron Aronofsky. His particular area of interest was why something like 78%, almost 80% of people who survived the Holocaust had great difficulty in reintegrating into what we would call normal society or normal life.

But he made a very conscious decision to say, “I actually want to study and devote my life to understanding the other 20%,” the people that did find a way to reintegrate. And so salutogenesis is really an exploration of all of the different elements that are necessary for us to thrive and to flourish as human beings. What are all those components? What are all the necessary aspects of life that allow us to feel as though we’re living from a place of abundance? We can dig into some of that in more detail.

By the way, this is in direct contrast to everything that I learned in medical school. There was no lecture, there was no department devoted to health and healing. All of our sort of intellectual pursuits in the medical paradigm have to do with understanding how things go wrong and then applying typically either surgical or pharmacotherapeutic solutions to those problems. I think that there’s great merit, I actually think it’s sort of missing half of the pie. There’s great merit in complementing our understanding of sickness and how things go wrong with all of the things that we need to be optimized in order to thrive.

Eudaimonics is also a very interesting word that goes… It’s obviously an ancient Greek word that means all of the attributes of wellbeing in one connotation. In another connotation, it speaks to a value-based exchange, where both parties who are in connection are up-leveled in their health and wellness and wellbeing. So if I sell you a Big Mac, I make money you get sick. If I sell you a grass-fed burger that comes from a completely different approach to raising livestock than the kind of commercial industrial perspective, in many ways that food can be nurturing and nourishing and healing. In that exchange, in that process, I can still make money and you can actually up-level your health.

What I think this is primary care renaissance that I’m speaking to ought to encompass is a combination of those things. An understanding, a deep kind of…. By the way, I think it’s so important that we orient the energy properly. This isn’t a reaction out of shame or despising or throwing mud onto the existing paradigm. This is an evolutionary process. It’s okay that things aren’t perfect. It’s okay in fact that there are all of these crises that we’re talking about.

What matters is how we respond to them. I think from an evolutionary perspective, what inspires me is in beginning to connect these dots, which by the way don’t require the creation of anything new. We don’t have to do anything new. We just have to connect the dots that are already existing in a better way. And I think salutogenic eudaimonics is a simple, even though it’s a mouthful, but it’s a simple kind of term that allows us to orient in the proper way so that we can see the primary care problems, the greater healthcare problems and kind of that metacrisis scenario and respond to it rather than react in partial or incomplete ways that only lead to more problems down the line.

What we’re trying to do with salutogenic eudaimonics is see the perspective in a much more holistic and integrated way so that we can respond to the problems that we face, but it’s going to take a different kind of thinking, obviously, as per the Einstein quote, than the type of thinking that caused those problems in the first place.

James Maskell: Absolutely. Just to give everyone some context, who’s listening to this, like the way that you have chosen to actually exemplify this or create with your time is to create this functional medicine, direct primary care practice called Cloud Medical, that you guys can also check out. It’s world-class. I’ve been to many, many clinics over the last 15 years.

I will say, from my experiences, it’s a world class technology operation, people operation, care operation and I have a number of friends who are members as well and repeat that back to me. But I want to dive into these 10 heartbreaks of medicine because it seems to me when I read those 10 heartbreaks that you had these feeling that these were the 10 key ways that medicine was breaking and then the result of it was for you to build Cloud Health.

Obviously, we’ve been here for a few years talking about this membership model for care and we’ve also been talking about salutogenic care delivered through functional medicine. Let’s just jump into them. It’s easy to remember these 10 issues because they all start with the letter P. So why don’t we just run through those quickly and talk about kind of what you saw as the problem and what you saw as the solution.

David Tusek: Sure. There’s a lot here. We could get stuck into some in some rabbit holes and in some weeds. I’ll try to kind of rip through them quickly. Maybe I’ll just read them first and then we can come back and hit which ones do you think are most relevant or interesting.

So the first one is that healthcare is the number-one cause of bankruptcy in the United States. Sometimes, we are tempted to just have a quick kind of response to this or a knee-jerk reflex and say, “Well, that’s simply because not everyone in America is insured. If only everybody was insured with commercial insurance plans, that probably would not exist.” That is just patently untrue. Most of the people and there’s great documentation on this, who are driven into bankruptcy through healthcare bills have insurance. We need to find broader and more nuanced solutions than just saying insure everybody or single pair.

Number two, the healthcare system is the third leading cause of death in the US. This was something that I first read Barbara Starfield’s initial publication in JAMA in the year 2000. To my absolute shock, I thought this was a kind of clock stopping event where it’s like, “What? How could this be possible?” It’s only been repeated since then. In 2016, Johns Hopkins repeated the exact same sort of actuarial analysis and study and they found that indeed, when you add up all of the iatrogenic conditions, so all of the sort of physician or healthcare system caused causes of death, it’s the third leading one of all.

Number three, we allow rampant conflict of interests and perverse incentives. I think that this is so much of what we’re all trying to do, like members of your community, James, the evolution of medicine community, I think we’re all struggling in our own way to find new payment models that allow us to keep the karma between our ourselves and our patients clean and pure. Something that’s a hugely important thing for me and something I’ve thought a lot about.

I believe that we need to really be careful and clearly discern when we’re talking about selling versus prescribing. I think so many of us struggle with that distinction. I’m not criticizing anyone. I’ve struggled with figuring out how to pay the bills myself but I have felt so gratified, so liberated, so lightened by never having to sell. At Cloud Medical, we’re a DPC practice. It’s a monthly membership program. Our average per member per month is around $80 a month, when you include families and businesses and individuals and couples and that’s it.

We don’t sell anything ever to anybody. We don’t mark up anything for profit. All of our supplements, the PRP, that we do the Botox injections that we offer, the surgeries in the office that we do, everything is either included in the membership at no cost or it’s at a break even cost for us. Practicing in this way and as I say, keeping that karma pure, so that I never feel that I’m incentivized or that there’s a conflict of interest to profit off of something that…that my financial model allows me to pay my salary and the staff salary and keep the lights on without actually being a salesperson, man, that is unbelievably fulfilling for me. I think many people should look at that as a beautiful way of distinguishing selling from prescribing.

The fourth, we often withhold power from our patients. This is a big one. This is a huge issue. This one stems from, I think, primarily the problem with time and the problem of band aid medicine and cookbook medicine and quick fixes and seven-minute visits. But we have to recognize I believe that there is a truly sacred opportunity. When you look at someone in the eye for the first time and you tell them, “You have diabetes. Your labs indicate that your hemoglobin A1c is nine or 10 and you’re a full-blown diabetic.”

That is a moment where time stops for that patient. The next words that come out of your mouth hold so much power and we have this opportunity, this amazing opportunity to harness that power and to hand that power over to them to absolutely ensure that the power remains with them and that they can now harness it in turn to optimize their lives, to change their health and to reverse their diabetes, which we both know is entirely possible.

But unfortunately, what happens in most cases and in the kind of conventional mainstream system is we don’t have the time to talk through that. We don’t have the time to orient the power so that it resides with the patient. And rather we say, “The power is right here. It’s in my hand. It’s in the form of prescription. I’m going to give you this prescription and you need to come back in 30 days to refill it and then we’ll check your labs again.” And when the patient says, “But what can I do?”

We don’t have the time and the bandwidth to unpack all of those things and it’s a huge squandered opportunity. There’s so much more to say about power. That’s a huge topic, but I’ll keep going just for the sake of time. Number five, we often discount the innate healing capacities of our patients. This is just another huge one. I feel that back to the notion of power, we can really twist it if we’re not careful. We can say things or do things that actually, everybody’s heard of the placebo effect. There’s also something called the nocebo effect, which is a negative force upon somebody’s health based upon a belief system that so many of our patients really hang on our words and they listen to every word.

If we tell them, “Listen, this cancer is going to take your life in three months,” or, “You will never walk again.” There are so many examples of people who basically said, ” That is not my reality. I don’t buy that.” They go on and they live another eight years or 10 years. Or they not only walk again, but they run an Ironman Triathlon. We’ve heard these stories. But I think that the point here is that not everybody has that capacity to respond to effectively a voodoo curse on the part of the medical profession with saying, “I’ll show you.”

In fact, I think that there are many people who actually contract around that and they say, “Oh, well, if the doctor says that, then that is my reality and they know more than me.” I think this inability or inadequacy of honoring and respecting our own innate healing capacity is something that we should really think about more.

I do and it makes me choose my words much more carefully. Number six is we often poorly rank risk benefit and cost benefit ratios and discount various biases inherent in publications. Look, the pharmacotherapeutic system is what gives us all of our tools. It gives us so many of our tools, not all of them, but so many of our tools, and I’m grateful for all of them. But not all of those pharmacotherapeutics are miracle drugs. Let’s be clear. Some of them are. There’s no question that triptan meds are lifesavers for people with migraine headaches.

Never mind all of the new magical evolution in bio science and for instance, nucleic acid therapies and they are absolutely going to revolutionize medicine. We should all be grateful as practitioners and physicians, for the brilliant minds that are giving us all of the tools to use to help people. But we should be very clear that there’s a broad range of these drugs where the risk benefit ratio is highly dubious, highly questionable. There may be much safer options even within the nutraceutical realm or the natural naturopathic or functional medicine realm.

I think we should be aware, a slavish and blind allegiance to consensus panels. A lot more to be said on that too, but I’ll just keep going here. We tolerate a lack of systemic transparency 100%. There’s this massive Wizard of Oz screen, most people can’t peer behind it. Oftentimes, it’s hard for doctors to peer behind it. But we need to on behalf of our patients. Again, this goes back to our reverent devotion to our patient’s best interests.

We have to look behind that screen and we have to make sure that we are aware of the potential bad actors that are doing things that are contrary to our patient’s best interest in a non-transparent way. We can dig into some of those specifics. Number eight, our patient privacy laws protect the wrong parties. Every doctor is beholden to the HIPAA Privacy and Security Act.

The fact of the matter is that HIPAA doesn’t protect your data from insurance companies, from the government and from other entities that potentially depending on who you are and your perspective and your point of view, you may want to shield your data more extensively than from the peering eyes of a passer-by or a neighbor. These are the entities that, for example, your genetic information and yes, there’s another act called the GINA Act that purportedly protects your genetic data from being misused. But there are already examples where that happens, where people have had due to unfortunate results in some of their genomic analysis, they had a mutation for instance, that increased their risk for a cancer gene, were then denied a life insurance policy.

So I think this is an area where we can be of great service to our patients and anonymize our data, which is something that we do routinely at Cloud with those types of tests. Number nine, we are far too beholden to special interest groups. This is the whole experts that are paid large sums of money by for profit companies. Again, I am a huge proponent of research and development. As I said before, I think we should have a tremendous amount of respect and gratitude for all of that that comes with it. But at the same time, we have to be clear and aware and open minded to the fact that big money is changing hands. Sometimes, that is in alignment with the best interests of our patients but certainly not always.

Number 10, our system is vampiric and the healers themselves have lost faith in our own profession. When healers are disillusioned and jaded and have unexpressed heartbreaks like some of the ones I’ve just pointed out, about the systemic dysfunctions, then the transmission to our patients can neither be salutogenic nor eudaimonic. We have to be, as I said before, as intellectually honest and as intellectually precise as possible to define the true causes of why our profession is so broken and take responsibility for that.

That’s the whole first step in any healing journey is to confront the darkness, to confront the shadow, to face it, even though it’s scary and uncomfortable and we’d rather not go there. That’s what we have to do. We have to heal ourselves, we have to heal our profession. Because the politicians won’t do it, because the politicians can’t do it. They don’t know how and they’re too entangled with special interest groups. That’s why I end on this note, who is left to lead the way forward towards a more sane and ethical system, if not us?

James Maskell: That’s it.

David Tusek: That is the call for the primary care renaissance.

James Maskell: Absolutely. Beautifully stated, I love those 10 Ps. And again, please, if you’re listening to this, go down, look at the ebook, there’s so much more in there. So I want to talk into the solution that we’re all working on and that you’ve been working on. In its first iteration, its Cloud. We’ll talk about some of the other things here in a minute. But first of all, just share a little bit about Cloud, the model, how it works and how it solves those 10 Ps and why it allows you to be in alignment and intellectually honest with the business that you’re creating. And then I’d love for you to just get into the question of can direct primary care really solve primary care? Because is there even enough physicians to go around?

There’s this argument that if everyone goes DPC, the poor people get left behind. And that was one of the first conversations we had where I really realized this guy’s actually thinking it through and is actually thinking at a sort of a meta level transformation that is actually reasonable and possible. And so I’d love for you to just share how all of those heartbreaks turned into Cloud and why you think DPC is the backbone of this revolution in primary care.

David Tusek: Yeah. Well, Cloud is always a work in progress. It’s an iterative process. It’s an evolutionary process. We’re always finding ways to be better at what we do. But I’m proud of what we’ve accomplished so far even though it’s by no means perfect.

I think that at the centerpiece of it is this notion that if we could do one thing to transform healthcare in America for the better and beyond America, United States, it’s for every person to have a personal physician on speed dial. I think that that is the most potent way to do that. I have obviously accumulated countless, countless examples.

I’ve been working and direct primary care for over 10 years. Countless examples of what that single thing of connection and communication and continuity has done to save tens of thousands of dollars in a single hour of coming in on a Saturday to treat urosepsis on a patient who had an ascending kidney infection, ascending UTI, giving them an injection of an antibiotic, watching their fever go from 104 to 103.

This was an adult male to afebrile in a matter of a couple hours, ordering an in home IV service, which we have, we’re very fortunate to have in Boulder County. For like $150, they’ll come in 24/7 to hang a bag of fluid. In any other scenario, this patient would have been in the ER and from the ER would have gotten admitted in to the hospital and probably spent a couple days they’re getting the same kind of treatment. The same thing happens over and over for complicated lacerations, for kidney stones. The list goes on and on. But I don’t believe that urgent care should be a thing.

When a patient is part of a DPC practice, their primary care physician is also their urgent care physician. So if something happens, on Saturday night, you cut yourself making dinner for your family, you don’t go to the ER for those stitches. We unlock the office, we come in and stitch you up. We give you a tetanus booster if you need one and you’re back home before dessert and there’s no charge for that.

Compare that to going to the ER, getting coughed on by 20 people with COVID or worse in the waiting room and waiting for six hours to get your stitches at a cost of $5,000-$10,000. If we’re just talking about the first one, the first heartbreak of payment and bankruptcy and what do we do to begin to not just flatten the curve of healthcare so that we’re no longer approaching $6 trillion in 2027. But we can actually start bending it down, I think this is where the primary care renaissance has to step in and say, “No. We have to do better. We can do better.” That allows us to be in a relationship that’s based on that level of caring, that level of trust that I was speaking about previously, without which we lose the passion for the practice of medicine and in doing so, we can offer a payment model.

The DPC offers a payment model that’s totally non-adversarial to the patient, doesn’t pit us against patients. I cannot tell you the degree of heartache before switching to a pure DPC, we endured, our practice endured because it’s just so disheartening when, I don’t know 20 or 30% of the time that a bill gets submitted, the patient feels ripped off by the insurance company or by the practice or, “But I thought this was covered. And this isn’t covered.” And it’s like, “We don’t control the details of your plan.” It just causes so much angst and actually disruption and a disturbance to the doctor-patient relationship, which is one based on attunement and healing energy.

And so, the cleanness of DPC as a payment model, the cleanness where it’s like, “Look, this is what it is per month. Nobody is making you sign a long term contract. Nobody’s holding you to this. If this isn’t a value proposition that makes sense to you, you can cancel at any time.” But if you want to be a Cloud member or a DPC member or any other direct primary care practice, you pay this small monthly fee, which for us in our group as it is for most DPCs, there’s 1,300 of them now nationwide, is around the cost of a cup of coffee per day. So $80 a month, give or take.

For that you get unlimited visits, no co-pays 24/7 access. You get to develop a relationship over time between that practice and those patients. It allows us to actually cut massive chunks of overhead out of the practice, out of the business side of the practice. The immense financial cost of billing is almost unimaginable and the energetic costs of that billing, the software platforms that you need and the clearing houses and all the expenses of…there’s billing departments where you have people employed as I did. I employed people to nothing but deal with the insurance companies to get that bill.

I think that that may be appropriate for neurosurgery or liver transplants and things like that. But for primary care, where we can do all of it, everything that we offer for 80 bucks a month? It’s utterly unnecessary. It’s misplaced. That would be like saying, we should use our Allstate Insurance that we use to insure our home against flood fires and tornadoes to pay for a broken toaster or to get our windows washed or to get our floors refinished. That’s just not sensible nor is it sensible in medicine when we can provide all that we do for such a low cost and to clean out all of this nonsense and this unnecessary burden. That’s really the word. It’s unnecessary. It’s unneeded, it’s undesirable. It’s unwelcome.

It’s so much easier to dispense without it. You can see I’m a little passionate about DPC.

James Maskell: Yeah, very passionate about it. Look, we only met in 2018. But obviously, you’d been on this train for a while. I wrote the book, the Evolution of Medicine in 2016, which was really…if you read that book, and many physicians have, the goal at the end of it was to get doctors to see that practicing functional medicine, AKA, salutogenesis in action, and delivering it with a payment model like DPC, which that was a whole chapter on could be. Obviously we’re thinking in the same way and I want to go into what that can look like as far as our agreement and where that’s going in a minute.

Let’s just lay out the math for everyone for a moment here because I know there is an argument that is made and I don’t know who’s making it, but people make it, that this DPC is rich people medicine. And that ultimately there could never be a system where everyone could have that kind of access to the kind of doctor that you’re talking about.

David Tusek: Yeah, thanks for bringing us back to that very important point. I think whoever is making calculations about the primary care workforce and is purporting that there’s a primary care shortage, I don’t understand how they’re doing their math. It’s well documented that we have over 220,000 primary care physicians in this country.

I think an optimal DPC practice is one primary care physician and one or two nurse practitioners or PAs. I work with a phenomenal nurse practitioner, Lindsay Chesley, who is functionally trained, who is every bit as competent as the best doctors I’ve ever worked with. I think we have this whole other cadre that we can tap into and collaborate with and really optimize our practice. And have one or two of those either PAs or FNPs working in tandem with a primary care physician serving around 1,500 patients. I think that is an absolutely workable model. And if you do the math, 22 or 220,000 MDs times 1,500 patients per practice, I think it comes out to 330 million which is pretty much the exact US population.

I think that we could move to such a model if we had the courage, if we had the resolution and the resoluteness. Very, very quickly. Look, as I said, Cloud is just one of 1300 DPCs out there. This is far from being an untried and untrue kind of fanciful pie in the sky model. This has legs, there’s a track record, there’s a proof of concept. I founded the first DPC in Colorado back in 2008 or 2009 or 2009, I think it was, and so it’s been around for over 10 years.

I think that for all of the reasons that I laid out, it seems to me to be the model that is most likely to be amenable to fixing the existential crises of primary care that I outlined, addressing or at least beginning to address the 10 heartbreaks of the healthcare system. And then moving even further outward in a broader way, is also impeccably aligned with the potential to contribute value to the sociocultural metacrisis, the ecological environmental climate problem, the multiple simultaneous pandemics that were in the midst of. It’s not just COVID obviously.

We have a health pandemic on the physical side of chronic disease, all driven by obesity. Then we have a mental health pandemic that our rates of addiction and meaninglessness. John Verve, he writes about the meaning crisis. These are very real phenomenon. And then we have a collective pandemic where our country is now reeling from the scars of slavery ultimately. The scars from the decimation of indigenous tribes that we have haven’t healed from, that we haven’t addressed adequately.

All right. I’m not saying that I have this answers or that that’s an easy thing to do to solve at all. But what I am saying is that these are real issues that require a healing approach to deal with. Guys, we’re the healthcare experts. So I think we need to have a role in this, we need to have a voice in this. Furthermore, you have these, you might call them the societal pillars, all of the industries and institutions and infrastructures that we’ve built our society on. Education pillar, the agricultural, how we grow our food, the law enforcement and criminal justice systems, the childcare systems, energy production, our economy and so on and so forth.

All of them are being called into question as in the sense that business as usual is not going to get us through. So we need to find ways of dealing with them. I believe that on a deep level, they all need to have a new source code spliced into them.

James Maskell: Yes, Doc, that’s super clear. And thank you so much for taking the time to share this and kicking off this series, this new season on reinvention of medicine and new models. And we’re super excited about direct primary care.

Look, direct primary care is a movement in its own right. Even outside of functional medicine and so I’m super excited to see these two things come together. It’s incredible what you’ve built at Cloud. I would encourage everyone who’s listening to this, go and get the ebook, download it, look at the 10 heartbreaks of medicine. It really spoke to me, I think it’ll speak to you.

Doc, thank you so much for kicking off this session so well. This is the Evolution of Medicine podcast. If you have questions, if you’re interested in going DPC, you can speak to one of our team at the Evolution of Medicine. Feel free to get in touch, you can book a concierge call with one of our team. Thanks so much for listening and we’ll see you next time.

Thanks for listening to the evolution of medicine podcast. Please share this with colleagues who need to hear it. Thanks so much to our sponsors, the Lifestyle Matrix Resource Center. This podcast is really possible because of them. Please visit goevomed.com/lmrc to find out more about their clinical tools like the group visit toolkit. That’s goevomed.com/lmrc. Thanks so much for listening and we’ll see you next time.


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