#24: Untangling the Knots in Primary Care: Dr. Winslow Murdoch on Direct Primary Care & Physician Advocacy

Justin Nabity
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Well, today we’re talking with Doctor Winslow Murdoch, a family physician who’s been at the front lines of medicine for over 35 years.He started as a solo practitioner, bu ilt a thriving multi-physician practice, and then made the jump to direct primary care long before it was the movement that it is today. Beyond patient care, Doctor Murdoch has been a relentless advocate for physicians, serving as a long-time delegate with the Pennsylvania Medical Society and pushing for real change in health care policy.

He’s also been at the forefront of medical innovation, mentoring doctors at point-of-care ultrasound and even using AI to make electronic health record systems more efficient. Named one of America’s top family doctors and a regular on Philadelphia Magazine’s Best of Philadelphia list, Doctor Murdoch has a wealth of experience and insight into the future of independent practice.

Doctor Murdoch, you’ve seen firsthand how primary care has changed over the years. Where do you think it’s headed next?

Dr. Winslow Murdoch
I think we’re at a crossroads where I think there will be a splitting up of how we approach primary care in the community. I think for young, healthy people who really don’t need a lot of health care services—more acute-related problems—I think the existing programs that we have, where it’s not necessarily relationship-based but problem-based, will continue.

And we’ll see the expansion of advanced practice practitioners filling in that role. There will be more and more integrated urgent care-type issues for the community. But for people that develop three-dimensional health care problems, I think we are going to see a dramatic change in how we deliver that primary care to the community—to have a medical home for those people who otherwise cannot be managed properly with the existing systems.

Neil Dougherty
Really quick—relationship-based versus problem-based. Tell me about that.

Dr. Winslow Murdoch
So again, for somebody who’s young and healthy and doesn’t have three-dimensional health care issues, they’re looking for problem solutions that are quick and efficient. Busy lives—they’re looking for quick care. And they can get that through the existing systems of how we deliver primary care in this country. But again, with more complicated patients, we need a different system to manage those people—to really be their medical friend and their ally.

Justin Nabity
Goes back to that patient-doctor relationship, the relationship that’s been strained. There’s been a huge divide. It used to be like this, and it’s gotten to be like this, with so many other parties involved in the process. And patients don’t really know where else to look to see what the cause of the problem is—except for the person that they’re closest to, which is oftentimes you. You’ve been working in direct primary care and other ways of doing things differently with your practice.

Tell us about what life looks like for you on a weekly or monthly basis.

Dr. Winslow Murdoch
Again, people think if you’re doing a lower patient number, of care that you provide for your population, you have a less busy job. And that’s not really true. It depends on how hard you lean in and how much the patients rely on you as their medical friend and connector for the rest of the health care system.

So, you know, it’s a full-time job. The grass is not always greener from an actual hours-committed-to-patient-care perspective. But the amount of things that you can do, the value you can bring to the equation, is dramatically different. I’ll typically spend four or five hours with a new patient—not face to face, but going through their medical records, pulling together information, trying to put together a long-term game plan, and medication simplification or correction, if you will.

A lot of people—it’s low-hanging fruit for new patients that come in who are complicated. Nine times out of ten, I’ll find dramatic drug interactions or mistakes that are being made that are really changing the patient’s life trajectory. I make those corrections in the first couple of visits. But there’s a big commitment of time to put the pieces together, which traditionally is not allowed in a traditional primary care environment.

That’s a big difference in what we do. And then for ongoing care, usually half-hour to 45-minute visits for follow-ups. Some people—it takes a half-hour just to vet their medication list on a follow-up visit because they don’t know what they’re doing. They have multiple specialists changing things, and you really need a lot of time to get down to what’s important for them.

Justin Nabity
It’s a great visual—that rope with all kinds of knots in it you’re trying to undo. And then once it gets pulled so tight, it gets really hard. You’ve got to rip your fingernails out a little bit just to get that thing undone, to get it opened up.

Dr. Winslow Murdoch
Absolutely. And then the relationship—you know, I don’t necessarily appreciate this in the moment. But when people recognize that I care enough to do that, when they come in for each of their visits, they’re much more likely to tell me what’s going on or where they’re having a problem. They lean on our team—not just me, but my office team.

I have a full-time front office person who is the coordinator and a clinical liaison who helps with drawing bloods and takes care of a super high-risk population of people with regular contacts to keep them out of trouble. They’re an important part of the team as well. And people look at us as part of their family. We’re extended family.

Reid Lancaster
I’m jealous.

Dr. Winslow Murdoch
Yeah.

Reid Lancaster
I’m not getting that care.

Dr. Winslow Murdoch
No, no. Again, if you’ve seen one direct primary care practice, you’ve seen one. We all have our priorities and strengths. We have things we’re interested in and things we lean into as priorities. And I just, you know, have found a niche for this population that I’m primarily managing.

Neil Dougherty
I don’t—I don’t feel like—I don’t want to be dramatic. Or maybe I should be dramatic with this. But four hours? That sounds like great care.

Reid Lancaster
Four to five. Four to five! I’m blown away by that number.

Neil Dougherty
What are people typically getting? Because it’s a roll of the dice. Most people are just like, “Hey, do you know a good doctor? Can I find a doctor?” or whatever. And you wind up somewhere where your insurance sends you. What kind of preparation would most people be getting?

Dr. Winslow Murdoch
Typically, for the larger health systems, they have access to care everywhere. An Epic-related product or link allows them to download medications that have been filled, diagnoses that have been billed for in the last couple of years, and bits and pieces of information. But putting it all together to create a cogent story—a couple of paragraphs on how things started, how things developed, what workup has been done—that takes a chunk of time.

So typical primary care practices will download what’s readily available in their EMR. They’ll take whatever comes up as working diagnoses. But when you actually go through it, a lot of those things aren’t really true. Or they were diagnoses to be ruled out, and they were ruled out, but they remain on the patient’s list.

I’ve seen some patients come in with 70 or 80 things on their Epic problem list. There are a lot more knots to untie to figure out what’s important and what’s not really accurate.

Justin Nabity
That’s a knot on top of a knot, is what you’re saying.

Dr. Winslow Murdoch
Yeah.

Justin Nabity
You’ve seen one direct primary care. You’ve seen one. Can you really explain why you say it that way versus saying, “You’ve seen one, you’ve seen them all?” Because clearly, they’re not the same.

Dr. Winslow Murdoch
Well, in direct primary care, we all try to invest more time with each of our patients to really provide a value-added service so that we develop patient trust and loyalty that will justify us charging an extra fee. It’s not through their insurance, it’s out of pocket right now. It’s post-tax money—they’re not paying with pre-tax dollars.

But the amount of time and bandwidth that a primary care doctor has and their dedication to leaning in, getting a patient figured out, and the knots undone is going to vary individually. Some people might be very comfortable managing people with chronic kidney disease, heart failure, and a whole host of other things.

Other primary care docs might be less comfortable with that, so they rely more on their referral network. Although, if you ask patients, they really want to have that primary care medical home that focuses on them and manages most of their care. So it really depends on the bandwidth, interest, and core competencies of the primary care practice, as well as the interest the doctor has and how much trust the patient has in the doctor to manage those things. It’s three-dimensional chess any way you look at it.

Neil Dougherty
This is super interesting. So what can we do?

Dr. Winslow Murdoch
Well, right now there’s really not a lot of resources to do intensive direct primary care. There are some individual companies that work with populations of Medicare and Medicaid patients, such as some of the Medicare Advantage plans that partner with companies like ChenMed to manage a higher-risk population that may have more socioeconomic barriers and hurdles to care.

But that doesn’t really fit the whole community. That fits a specific population with limited coverage benefits through that Medicare Advantage plan. I think that if we can find a way to identify patients that are more complex and require more three-dimensional, resource-intensive primary care—not in the traditional model of fee-for-service or inexpensive direct primary care where the patient’s out-of-pocket cost is maybe $75 or $100 a month—that’s not going to work for this population. This population needs more resources in primary care than that.

That requires some unique and out-of-the-box thinking to build a system where that is supported and sustainable in the community for primary care doctors who want to do it. And that’s a whole new horizon.

Justin Nabity
How do your colleagues respond to you when they hear about what you’re doing? If they’re not following in your footsteps or doing something similar, what’s their reaction? Do they think you’re doing something that is so beyond what’s possible? Is it unreachable from their perspective? Are they inspired by it? How do they process what you tell them about your work?

Dr. Winslow Murdoch
Well, if you work in a traditional model that accepts insurance, what we do at our office—you can’t do it. You don’t have the resource of time to really coordinate. Even if you had an army of social workers and nurses, you don’t have the time to build that relationship and dedicate yourself to truly knowing that patient inside and out. So it’s always more transactional in that kind of environment.

For other doctors doing direct primary care, because their reimbursement model is generally $100 a month or less, they don’t have the resources. If their practice is growing rapidly and they’re starting to fill up their panel with 400, 500, or 600 patients, they lose the bandwidth to manage care in this way.

Dr. Winslow Murdoch
So they think it’s interesting. They kind of say, “Oh, you do that too? Oh, you do that too?” They’re impressed by the breadth of what we can do. Especially when we talk about having a point-of-care ultrasound—that really extends what I can do from a physical exam and diagnostic standpoint at the point of care. I don’t charge for that; it’s just part of my physical exam.

But a lot of people say, “Oh, that’s cool, but it’s just not applicable to the environment I work in.” So it’s maybe an aspiration for some people, but for others, they just don’t want to take on that level of complexity. If it’s going to make them bleed out of their ears trying to figure out that knot, they’d rather pass it off to someone else. It really comes down to the individual and their tenacity to figure those things out.

Reid Lancaster
Doctor Murdoch, what got you to the point where you wanted to provide this type of care? Because you could decide not to untie probably 60 to 70% of those knots, but you’ve decided to untie them. What got you to this point?

Dr. Winslow Murdoch
Well, it was sort of an interim transition. I started off independent, solo, grew to five doctors, a nurse practitioner, and a PA. I sold to a hospital system. Then, after about five years, the hospital system decided to go for RVU-based reimbursement for the doctors. Suddenly, all my colleagues wanted to send all their complicated patients to me while they took care of urgent care—same-day, simple stuff.

And I realized that wasn’t a model I could survive in. So that’s when I branched away. This was back in 2001—we’re talking a long time ago—to start this model in its initial stages. Over the next three or four years, we built the model into what it is today.

Reid Lancaster
So filling a need, basically, is how this got there.

Dr. Winslow Murdoch
And I tended to collect some of the more complicated patients in my larger practice. It was a win-win for me and a win-win for my patients at that time, making the transition.

Reid Lancaster
We’re starting to get more and more patient following—not just physician following—at DocNation. Could you explain why, because of the RVU-based model, your colleagues would send you the more complicated patients?

Dr. Winslow Murdoch
Right. So, in a reimbursement model where a doctor takes traditional insurance, they can schedule different levels of complexity for a visit. But because of the way things are reimbursed, they want to simplify their scope of work during an office visit.

Typically, you get paid the most for taking care of one problem. If you take care of two problems, the multiplier for what you get paid is diminished by maybe 50 to 75%. If you take care of three problems, it’s diminished even more. So the focus of the clinician is: identify the most urgent pressing problem—either medically urgent or the patient’s quality of life urgent—and just focus on that. They tell people to come back for follow-ups.

But in reality, a lot of these issues feed off of each other and really should be handled in a longer visit. Traditional insurance doesn’t pay for that cognitive time to figure those things out. It pays for transactions—one problem per visit. That’s not a good model for complicated patients in the community.

Reid Lancaster
So a patient needs help, but they don’t just need help for the biggest-ticket item. That’s the misalignment, right? It’s just a mismatch.

I have a lot of friends who listen to this podcast. More and more are tuning in. And they’re asking, “Why such a disdain for the insurance companies?” If I could just speak in layman’s terms, the doctors don’t want to do what you think is the best way because they won’t get paid for it.

They have to feed their families too. This isn’t just a huge money grab by physicians. If they did this all day, every day, they wouldn’t make money. They couldn’t sustain it. It would be an expensive hobby.

Justin Nabity
Is that where we are now? The medical profession has been reduced to an expensive hobby?

Dr. Winslow Murdoch
If you want to do a good job and work within the system, yes—it’s a very expensive hobby.

Reid Lancaster
My wife said, “I’ve never heard you say the word ‘hate’ so much in your life until we started talking about insurance companies and hospital administration.” And I said, “Well, I think I feel that way. I think I really feel that way.” There’s a genuine hate there because we’ve taken our highest-educated group of people and said, “We’re not willing to pay you to keep America healthy.”

That’s what it comes down to.

Dr. Winslow Murdoch
And people don’t realize that a typical primary care practice’s overhead is close to $300 an hour before the doctor gets paid a penny. If your insurance is paying $70 for a visit, that’s a lot of visits just to cover the overhead before the doctor can walk home with a nickel.

So you’ve got to really change the way you practice and work within the rules of the system—which aren’t helpful for the physician or the patient.

Neil Dougherty
I’ve been hearing a lot lately about treating just one problem at a time, keeping the patient coming back, and doctors talking about algorithms instead of treating everything all at once. And it’s concerning. The data on patients—there was a term for it: conservative care decay, or referral fatigue. Patients would just give up.

Dr. Winslow Murdoch
And even if they have a good primary care doctor, specialists are stuck in the same system. If they can’t figure out the issue in a visit or two, they say, “Go back to your primary,” and we’re left to cut bait and go back fishing.

But primary care docs can offload a lot of the routine, redundant stuff that specialists do—ease up some of the burden on the ER, reduce the backlog for real specialty-related care—if they have the resources to manage multiple problems per visit.

This isn’t for everyone with a stubbed toe, an ingrown toenail, a boil, or a sore throat. This is for people who need three-dimensional care, where one decision has a knock-on effect on four or five other conditions they’re experiencing.

It’s a different game than traditional care. Right now, if someone goes to urgent care and they don’t respond to the therapy they were given, they bounce back to primary care with a more complicated problem than they initially had. That knot has to be untied as well.

We really need to reimagine the way primary care is resourced so it can do the job it’s capable of doing.

Reid Lancaster
I’ve been working in medicine for a long time now, and I had a conversation two days ago with someone in my neighborhood that really broke my heart. He’s a very successful, very smart guy. But he told me, “I go on Google, diagnose myself, call a friend who can prescribe me something, and then go to Walgreens and pick up my medication. I’m done going to the hospital. I’m done seeing anybody.”

And I thought to myself, this is the greatest country on Earth, the greatest country in the history of civilization, with everything at our fingertips. And yet, here’s this educated guy saying this. It’s a disappointment.

Doctor Murdoch, you hit the nail on the head with everything you’re saying. And my wife hears me talk about this and says, “I can’t believe you said that.” But I get it. It makes complete sense to me.

This guy bounced from one doctor to the next—four different doctors in one year. And he said, “It wasn’t that they weren’t smart. It’s that I could never have a conversation with them that got me to where I needed to be.” And he was mad at them.

That’s the issue. He was mad at them, not understanding why they have to churn and burn, why he only got 30 minutes with each one of them.

Dr. Winslow Murdoch
Our time as clinicians is precious. So finding ways to be more efficient in our day-to-day work is critical.

Using AI to help with chart notes when you’re touching on four or five different problems during a telemedicine or office visit, using smart ordering for labs, having templates—doing things behind the scenes to improve efficiency lets us have more bandwidth to untie more knots.

But the more knots they throw at us—through prior authorization, pre-certification, and all the other nonsense—the fewer knots we can untie. We get tied up with administrative stuff. And that doesn’t go away in direct primary care because patients still have Medicare or a commercial insurance plan with all those hurdles.

We just have a little more bandwidth to fight for the patient. But that time comes at a cost—it takes away from our ability to handle other things. And that’s another reason why patients are frustrated: their doctors have less and less time to give them.

Justin Nabity
How long did it take for you to know that this was the right move? Because you’ve taken a risk, pioneered something new—made moves that most doctors have never made or even contemplated making.

With direct primary care, how long did it take you to realize this was the right path?

Dr. Winslow Murdoch
Thirty seconds.

Financially, it was disastrous for my family for the first couple of years until we got things up and running properly. But right away, I became energized and passionate about being involved in organized medicine—the medical society, our county medical society. I’ve been very active in working on these issues from a systemic level, not just in my own day-to-day practice.

As soon as I switched to this model, I thought, “Oh my gosh, I have to share this with other people and get involved to make this the norm.”

Twenty-three, four years later… almost there. Almost there.

Neil Dougherty
I got this.

Justin Nabity
It was worth it. That two-year struggle was worth it. You knew it was right from the start.

Dr. Winslow Murdoch
Yep.

Justin Nabity
Thanks so much for being on with us, Doctor Murdoch. This is exactly what patients need to understand.

The problem isn’t the doctor. It’s everything that handicaps doctors—tying their hands behind their backs, limiting them. And, Reid, what you said about what your neighbor is dealing with…

Reid Lancaster
It turns the patient against the doctor because of a lack of education and understanding—an education and understanding that a patient shouldn’t have to have.

They shouldn’t have to understand RVU rates. They shouldn’t have to understand why they only get 30 minutes. They should just be able to get the care they need. But they can’t—unless someone like Doctor Murdoch steps up.

But we shouldn’t expect doctors to be pioneers. We should expect doctors to be doctors.

There are too many fundamental problems in health care that we’ve been fighting for years. And it’s not getting better. It’s not getting better.

So the real question is, how many Doctor Murdochs are going to emerge in the next four or five years? Because with AI coming in and taking over certain aspects of health care, we’re going to see monumental changes.

Dr. Winslow Murdoch
It’s a fun time—scary, but fun. And I’m optimistic.

From a full-career perspective, this is a great way to finish. I’m 65—maybe five more years in the tank. But it’s a good way to bring closure, to see the continuity of this model, and to know that it was the right thing to do from the start.

That’s what got me through the rough times.

It’s exciting. And thank you so much for having me on.

Neil Dougherty
Thank you, doctor.

Reid Lancaster
For all the work you’ve done for us—thank you so much.

Justin Nabity
Thank you.

Dr. Winslow Murdoch
It’s been a pleasure.

Justin Nabity
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