Sulagna Misra, M.D.: On Misra Wellness and Direct Patient Care

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): The Good Men Project

Publication Date (yyyy/mm/dd): 2024/12/09

Dr. Sulagna Misra, MD, BCMAS, is the founding physician of Misra Wellness®, a Direct Primary Care (DPC) practice that focuses on weight loss, men’s health, integrative medicine, primary care, and aesthetic medicine. She is certified in Integrative Medicine, Internal Medicine, and Aesthetic Medicine, offering a broad range of medical and aesthetic services. Born and raised in New York City, Dr. Misra previously practiced at Mount Sinai Hospital before transitioning to a role as an Integrative Medicine practitioner and Laboratory Director in Midtown Manhattan. Now based in Los Angeles, California, she strongly advocates patient-centered care, emphasizing the importance of the doctor-patient relationship in healthcare. Dr. Misra promotes price transparency and provides personalized consultations on patient education and ongoing communication. Guided by her tagline “Feel, Heal, Reveal,” she supports patients on their journey to optimal health and wellness. She has been featured in Forbes, US News and World Report, Men’s Health,Yahoo, Newsweek, International Business Times, and S.F. Examiner. Misra discusses the challenges of healthcare systems, particularly Medicare and Medicaid, which restrict patient care choices. She emphasizes the benefits of Direct Primary Care (DPC), advocating for price transparency and a more personalized doctor-patient relationship. Misra also critiques the growing role of nurse practitioners, AI, and corporate medicine, highlighting the need for reform in healthcare structures to improve patient outcomes.

Sulagna Misra, M.D.: You’re the first to ask for my consent to record. Everyone else assumes I’m going to say yes. Thank you. 

Scott Douglas Jacobsen: I’ve learned from interviewees that asking for consent, such as free, prior, and informed consent, is not uncommon but not common.

So, I’ve established certain policies, with a few exceptions depending on the particular theme, case, topic, etc. Today, let’s get to the topic at hand with Dr. Sulagna Misra. You’re a founding physician of Misra Wellness, correct? Registered? So, what inspired you to pursue medicine, and why did you found Misra Wellness?

Misra: All right, I have a long history with medicine. First, I come from a family of doctors, so medicine is generational for me.

That’s a big factor. The second thing is that I didn’t want to become a doctor—true story. I fought it. I did the “good doctor’s daughter” thing because I’m Indian. Culturally, that’s largely expected. My mother and I had disagreements. I was a singer, dancer, and artist, and that’s the path I wanted to follow.

I was writing my music and didn’t study for my MCATs because I didn’t want to go into medicine, so I didn’t perform well. I went to NYU and majored in biochemistry, and my mother and I had an agreement. She was also a singer, and we both had opportunities to be on the radio.

I want to work with a producer in New York. I’m originally from New York. I was born in L.A., raised in New York, and then moved back to L.A. I’ll tell you more about that later. 

Jacobsen: You give off New York vibes.

Misra: I’mmuch a New Yorker. I hope I’m not losing that. All my music was stored on my computer, and I got accepted to a Caribbean medical school. I planned on starting in September, but they offered early enrollment in May. At that time, I was a licensed real estate agent.

I got my real estate license and planned to make money while pursuing my artistic passions. But instead of following that plan, my mother said, “Go for one semester to the Caribbean, to Ross University. If you hate it, come back, sing, and do other things. If you love it, stay with medicine.”

So, I went. However, I didn’t back up my music files because I’m not tech-savvy. Then, my computer crashed, and I lost all my music. On top of that, my mother was diagnosed with cancer.

She had ovarian cancer. She was young and a doctor herself. I didn’t even know about it because I was in the Caribbean. The call I got after my computer crashed was from my uncle, saying, “Hey, your mother has stage 3B ovarian cancer.”

She had everything removed. She’s out now, but she was hospitalized, and I was , “Oh my god.” I wanted to fly back but couldn’t do anything for her.

I couldn’t help her because I didn’t understand cancer. So, I decided they only needed me there for 12 to 16 months since it was the Caribbean. Then I could continue everything in the U.S. So, I thought, let me finish my program here, and then I’ll return to help my mom. Because without understanding the pathophysiology of the body—normal and abnormal—you can’t fight cancer. I couldn’t help her.

So, to help her, I changed my residency to be able to live at home and take care of her while attending residency at Staten Island University Hospital, where she was from, Staten Island, which is now Northwell. Instead of the six months they gave her, I helped her live for five years. I got her out of Staten Island University Hospital, where they misdiagnosed her, overmedicated her, and all of that. We got her into Sloan, and she was treated at Sloan Kettering.

Unfortunately, it was aaggressive cancer, and she passed. When she passed, my father also passed. My grandparents had passed, too, so I had six deaths back to back to back. It was so overwhelming for me. I needed a fresh start.

So, I left. I was working in private practice then because I had left Mount Sinai. I wanted continuity of care. I hated seeing patients come in and out of the hospital without being able to prevent them from returning. That’s when I decided I wanted to do outpatient medicine. I didn’t want to be a hospitalist anymore.

I wanted to be the doctor that patients saw regularly. So, I worked for Integrative Medicine of NYC. When my dad died, it was as if my body fell apart. I needed time to grieve, but that’s not allowed as a doctor, so I had to leave. I had to take care of my mom’s affairs, and eventually, I moved to L.A. to start fresh.

That’s where Misra Wellness was born. 

Jacobsen: How do you bring integrative, internal, and aesthetic medicine together? And how do we define each of those terms for non-medical people? 

Misra: I have a tagline: “Feel, Heal, Reveal.”

That came from a love of rhyming since I was a songwriter. But it also reflects my philosophy of wellness. No matter where you are on your journey to wellness, I’ll meet you there. Part of wellness involves dealing with internal issues—feeling and healing internal trauma or medical issues. Then, the “reveal” is whatever your optimal version is.

I integrate medicine by following Maslow’s hierarchy of needs, which I apply to almost everything. Maslow’s pyramid is a structure,  the food pyramid, where you work from the base up. The foundation includes essentials:  sleep, food, and shelter. For some people, it can also include sex.

Not everyone includes sex in the pyramid because, for some people, sex can be traumatic or associated with pain, so it needs to be higher on the pyramid and carefully addressed. That’s also how I approach integrative medicine. I also teach about this on a national VuMedi platform. It’s a physician education platform where I teach other physicians how to build their dream practice and prevent burnout based on my experiences. It’s hard for me to separate internal, integrative, and aesthetic medicine because everything is interconnected.

For example, let’s take weight loss—medical weight loss—a huge field, especially in obesity medicine (pun intended). When we start medical weight loss, patients begin to see results and finally feel heard and better; they want more for themselves. They want better financial flexibility and better working hours. The time they spend mindlessly eating,  sticking their head in the fridge—I know because I used to do that—becomes extra time.

And that’s where deeper issues come up,  suicidality, depression, and anxiety. What is your brain doing with all that extra time? That’s where integrative medicine, internal medicine, and aesthetic medicine come into play. They’re all related. When people start feeling better, they want more for themselves.

So, when my patients step on the scale and finally see progress, they often want more. They want financial advice, an organizer to help declutter their home, a therapist, or aesthetic treatments. Maybe they want something on their face treated, which they were too ashamed to show. They say, “I can show up, step up, and be seen, and I want to be seen differently.” It’s beautiful. That’s  one aspect.

Jacobsen: There are many aspects. What do you find is the hardest thing for people to get through?

Misra: Acknowledging it. The first step to any change is acknowledging that you need help and that there’s a problem. So, acknowledging that your weight is a problem, your energy is a problem, your sleep is a problem, your libido is a problem, your social support is a problem—that’s the only way to start identifying how to create a solution. That state is called a precontemplative state.

When you’re still aware that a change needs to be made and aren’t initiating the change, the doctor can only meet you there if you say something. That’s why I emphasize communication and regular contact, which is why I practice direct primary care. Direct primary care is a medical movement where doctors don’t accept insurance and offer affordable monthly memberships.

Jacobsen: Can you give me more detail about direct primary care? I’ve interviewed an epidemiologist named Dr. Gordon Guyatt several times, even recently. He works on evidence-based medicine, and he emphasizes the role of values and preferences. People can determine, at a societal level, the kinds of health care they want access to and choose from what is available. If you value equity in Canada, you prefer national health care and a pharmacare approach. In the United States, where autonomy is of great value, people tend to prefer privatized medicine more. Does that factor into the direct primary care (DPC) mindset and framework?

Misra: Yes, it does. DPC started with a group of family medicine doctors addressing the lack of access to physicians in rural America, particularly in the Midwest. In those states, DPC doctors might exchange services for membership fees. For example, if you raise chickens and have fresh eggs, your doctor might accept fresh eggs as payment for that month.

Or, if you have cattle and butcher, they might accept fresh steak. That’s how the movement began. DPC aims to remove administrative burdens and insurance from the equation. Insurance, in many cases, is fraudulently practicing medicine. It’s racketeering. They raise premiums and deny care even when doctors write medically necessary prescriptions.

For instance, doctors might prescribe a medication, and insurance will say, “Nope, you don’t meet the standard,” even though the patient does medically. This is why DPC is gaining traction—beyond burnout, there’s also moral injury for doctors. It’s frustrating when we say, “You need this medication,” and the corporate entity or insurance we work for says, “No, you can’t have it because it doesn’t meet our criteria. We don’t want to spend money on preventative care; it’s too costly.” Insurance isn’t working in your best interest.

But if you pay the doctor directly, we work on your behalf. People often think doctors are rolling in money because insurance premiums are increasing, but that’s not true. Doctors are losing money. We’re receiving less and less in reimbursements. For a time, I accepted Medicare and tried to have a hybrid practice with DPC and Medicare.

However, my Medicare reimbursements dropped so much that I spent more than I earned. I was literally in the negative. I had to stop accepting Medicare. So, you’ll see more doctors leaving the system because they’re not getting paid—especially primary care doctors. Our work is preventative; we’re not performing surgeries or procedures where the money is. Yes, this factors into DPC.

Jacobsen: Is this also tied to the larger issue? I’m not talking about individual cases.

Misra: They are all tied together. There’s also a significant financial burden regarding end-of-life care, where medical expenses are the number one reason for bankruptcy in the United States.

This is why I’m shouting from the rooftops. I’m human, and I need care too. Right now, I’m going through my medical challenges, and the nightmares I’m encountering are shocking. I shouldn’t be going through this—I’m a doctor. I know how to navigate the system. Why is this so difficult? If I, as a doctor, face these issues, I can’t imagine what my patients are going through. They often don’t even understand what’s happening.

And I’ve realized that many other doctors don’t fully understand what’s happening. We’re getting shouted at because we’re the system’s front face. The insurance companies aren’t saying, “Hey, we deny your claim.” No, the doctor delivers that message: “Your insurance denies this.” But the truth is, you chose your insurance plan, and you negotiated that contract with them. We didn’t negotiate that. We’re  dealing with the results of your negotiation.

When you remove insurance from the equation, you discover the actual cost of things—which is what direct primary care does. For example, compare the prices under a Blue Shield platinum PPO plan or an Aetna platinum PPO plan versus the prices I can negotiate through direct primary care. Sometimes, I save patients hundreds of dollars. Suppose you’re on a men’s health plan where we’re doing your PSA, hematocrit, testosterone (free and total), estrogen, and sex hormone-binding globulin tests. In that case, insurance may charge you a significant amount. But through DPC, it could cost much less. So, where is that extra money going?

This is important now because open enrollment started two days ago. Suppose people know about direct primary care and realize they can get preventive care and access to a doctor for a low monthly membership fee. They can avoid running to the E.R. or urgent care whenever they have an issue. We can help triage them. For instance, I had a patient before you, and I had to tell him, “Look, your situation sounds urgent. Here’s what you need to do.” Without me, he had an HMO plan and needed to figure out where to turn. He might have ended up going to the E.R. unnecessarily.

It wasn’t an ER-level emergency, so he probably would have been sent back to his primary care doctor. He would have been bounced around. when you go to the hospital or these places now, you’re not even seeing doctors anymore because non-physician practitioners have been given the legal right to practice medicine by corporations and insurance companies, who think it’s cheaper. But in reality, healthcare costs are skyrocketing, and they’re making a mess of things.

Insurance companies offer something akin to a “bureaucracy” in healthcare. They’re breaking the RICO Act at this point. This is racketeering. They operate based on fear—fear that you’ll get cancer or be in a motor vehicle accident. They should be operating under a preventive care model, but they’re not. most patients don’t even realize this. For example, let’s say you, Mr. Jacobsen, have a cough but also need your regular annual physical.

My cough annoys me, so I’m going to my doctor for my regular physical and will bring up my cough. “No. No. No. No. You can’t do that because we can’t bill for a good visit and a cough simultaneously.” So what do you do? What’s more important to you? It’s  a game—medical gymnastics—what doctors are doing now.

Instead of performing these medical-gymnastics, which are leading to burnout, moral injury, and so much more—including suicidality—we’re facing the highest suicide rates. We didn’t have the highest rates before COVID, but we do now.

Dentists used to have the highest suicide rates. Now, doctors are leading, and many are leaving medicine altogether. It’s a massive problem. This is an epidemic. People are dying, and people are sick—for no real reason.

Jacobsen: I interviewed a doctor who left due to M.D. burnout in the U.S. He’s now working in Quebec and praises the conditions and improvement in his health since moving. Maybe I’ll link to that—it could be an interesting connection. 

Misra: I’m noticing much rage toward the system.

Jacobsen: Right. How has this become such a malignant problem? 

Misra: It has grown completely out of control. I’ve heard from many qualified professionals that this is an issue, but you’re addressing it head-on.

Jacobsen: The people I’ve heard were more cautious while you’re talking about it directly.

Misra: Yes, because doctors are so afraid to speak out. We’re trained in an abusive system. I’ll say it as it is—it’s a hierarchical, abusive system. If you speak up, you’re punished, and we carry that with us. When applying for positions, it’s , “There are two positions and 5,000 of you. Go.” They pit us against each other to fight for those two positions. So, we’re trained not to be collaborative.

We collaborate only around a patient, but we’re trained to compete with each other. That lack of collaboration is part of the problem. We needed help, and they gave us nurse practitioners when we asked for help.

That was great for a while—until nurse practitioners started thinking, “What’s a doctor doing? I can do that.” Then the insurance companies and corporations agreed, saying, “We think you can do it too. We’ll pay you more than you made as a nurse but less than a doctor.” They d that because it saved them money.

Misra: And now, a lawsuit drives me up the wall in New York. Nurse practitioners are suing, saying, “Hey, we do the same work as physicians, but we don’t get paid the same. since we’re mainly female, this is a hate crime.” What about the actual female physicians in New York who aren’t getting paid the same as male physicians because of gender inequity and pay disparity?

We’re not suing, and that’s an actual hate crime. However, nurse practitioners are suing because they’re 80% female.

Jacobsen: Side question—I’ve seen this come up too. Some groups have lobbied or sued to use the title “physician.” I believe this was naturopaths in the United States.

Misra: Yes, naturopaths cannot use the title “physician.” The good thing is that the title “physician” is reserved for M.D.s, D.O.s, and MBBS graduates. The term “doctor” has been watered down. So when you go into the hospital and see someone with a stethoscope and a white coat labelled “doctor,” they could be a doctor of nursing practice (DNP).

That means they didn’t even have to go to college for some of these nurse practitioner programs. I don’t hate nurse practitioners—they have a role—but they’ve blurred the scope lines. They don’t know what they don’t know because they haven’t attended medical school. For example, I’m an internist and integrative medicine physician. You wouldn’t see me performing groin surgery unless it was an emergency,  if someone was bleeding out and we were stranded on an island with no other options. In that case, I’d try to save a life.

But I know what I can and cannot do and when to call on my colleagues’ expertise. That’s what nurse practitioners don’t know—they don’t know their limitations. They don’t realize that not everything is solved with an antibiotic, a steroid, and IV fluids. There’s much more to it, and they’re unaware of that.

So, you go in with a cough, thinking you’re seeing a doctor, but it’s not a doctor. They might say, “Let’s have you see an ENT because we don’t know.” They might do an X-ray but still have no idea what’s causing the cough. They don’t know that the cough could come from your brain, diaphragm, lungs, or even an OCD tick. It could be psychiatric, lingering from a post-viral cough, or—worst case—an indicator of cancer.

They don’t know. So they sent you to the ENT, which hired a nurse practitioner. That N.P. might not know how to scope you properly because they’ve never gone to medical school and don’t recognize the signs of cancer. Then they’ll say, “Your cough seems fine. Maybe you should see a lung specialist.” You go to the pulmonary N.P., and still, you’re not seeing a doctor.

Six months later, the cough worsens, and you start coughing blood. All this time, you thought you were seeing doctors, bouncing from specialist to specialist. But none of them were doctors, yet you’ve been paying as if you were receiving care from a physician.

By the time you’re hospitalized, it’s too late. Occasionally, a doctor finally steps in, looks at your case, and goes, “Oh my god,” and fixes everything because that’s what we do—we catch things. But with fewer doctors in the system, we’re scaling ourselves out. Doctors are leaving the system.

Jacobsen: It sounds  a dangerous situation for patients unaware of these distinctions.

Misra: We’re burnt out. We’re becoming entrepreneurs. Look at me—this is what’s happening. It’s all connected. “Practitioner” is a bad word—it doesn’t mean you’re a doctor. “Physician” means you’re a doctor. A Doctor of Nursing Practice (DNP) is not a physician. They’re not medical doctors; they’re doctors of nursing practice.

What do they learn? Nursing theory and nursing lobbying. Let’s put nursing theory and lobbying aside and do a medical exam. So, they’re replacing real doctors. But they’ll start complaining, too, when A.I. steps in because it’s moving fast. A.I. will replace us all eventually. For doctors, A.I. is a tool we use to write notes faster and create emails more quickly using specific language. We don’t replace ourselves with A.I. However, nurse practitioners will get replaced by AIbecause it’s safer for AI to do what it does than for nurse practitioners to keep doing what they’re doing.

The DEA is also conducting its investigation. All these separate investigations are happening because we don’t have the data yet—it all got worse during COVID-19. Have you heard about Dunn and Cerebral?

Jacobsen: No, I’m not familiar.

Misra: Oh my god, let’s go. Dunn and Cerebral were two telemedicine companies that were pushing Adderall. They were the reason for the Adderall shortage. They started hiring nurses and some doctors who didn’t fight back, and they were telling them to prescribe Adderall without even following up with patients. It was all about pushing the prescriptions. This created a shortage.

So, people with legitimate ADHD couldn’t get their medication during the COVID-19 shortages. When I was doing men’s health during that time, most of my male patients were on Adderall. I’m like, why the hell are you on Adderall? You have hypogonadism. You’re not producing testosterone. That’s what we need to fix, not put you on Adderall.

Now, we have to wean them off the Adderall they’ve become addicted to. It isn’t pleasant. the poor ADHD patients who need it couldn’t get their meds. It isn’t good.

Jacobsen: I can see why you’re worked up. This is serious.

Misra: I get worked up because this is not what I signed up for. None of us did. As doctors, we’re promised two things: the ability to care for others and save lives and job stability. Both of those promises have been taken away. Insurance companies and the corporate takeover of medicine are destroying everything. Hospitals are falling apart, and insurance companies  UHC and OptumRx are fraudulently practicing medicine.

Jacobsen: Do you think there will be a rapid revolution in how medicine is structured? For example, could racketeering be addressed with the rise of DPC and limits on insurance overreach?

Misra: The problem is that for words  “racketeering” and “fraud” to be used, someone high up and famous must be hurt. That’s when people will start paying attention. Someone famous. Someone in government. A celebrity. But these people can afford doctors, so doctors will leave and create our system. We’re already working on it.

Jacobsen: And what about recruitment? Bad news travels fast. Doctors are leaving the country, or individuals are moving toward DPC and restructuring, right?

Misra: Yes. 

Jacobsen: So, what happens if you scare off potential new doctors who are already U.S. citizens or even those coming from overseas with visas  the H-1B? The U.S. has traditionally pulled in talent worldwide, creating a massive brain drain toward America. Still, people might need guidance to pursue that path.

Misra: I’m a civil surgeon and do immigration physicals for the Department of Homeland Security. Some of the doctors I see come to me for U.S. residency. I perform independent medical exams to ensure they meet the requirements. I ask them, “What are you going to do once you get your residency and immigration status?” Do you know how many of them tell me they’re going back to their home countries?

I’m , “You’re not staying here? You’re working here and leaving as soon as you get your paperwork?” It’s because things are so bad here. I see it.

Jacobsen: Which state do you think is the worst regarding the upcoming physician shortages?

Misra: Everywhere, but especially the rural areas. When nurse practitioners were given more autonomy, they promised to provide coverage in rural areas. But that’s not what happened. Instead, many opened med spas, IV drip clinics, or aesthetic treatment centers. They didn’t go to rural America. You can be an N.P. urologist one day, a cardiologist the next, and then move on to pediatrics or pulmonology in the ICU without any consistent specialization. It isn’tcomforting.

Jacobsen: So what does this mean for the average citizen’s access to medical care? The wealthy can afford good care in good times and bad. What does this look like in a system that should provide quality care for everyone, especially in a privatized healthcare system?

Misra: The best way to illustrate this is to run through a typical insurance visit. Let’s pretend you’re seeing a doctor.

Jacobsen: Sure, let’s do it. I’m all ears.

Misra: Let’s say you have a cough or a UTI. 

Jacobsen: Let’s go with a cough. 

Misra: You come to your primary care doctor.

Jacobsen: I’ll give you an example: I was voluntarily released from the military after getting a body check on my ribs, and I had trouble breathing for a while.

Misra: So, you have trouble breathing. The first thing you’d probably do, depending on whether you have an HMO or a PPO, is look at your insurance card and ask yourself, “Do I need to go to my primary care doctor, the ER, or urgent care?”

You probably need a doctor to call directly, so that’s the first hurdle. Then, if you contact your primary care doctor, they’ll ask, “Can you breathe?” If yes, they’ll tell you, “You’re not going to the E.R. or urgent care. We’ll book you for an appointment, but it might be four months out.”

If you have a broken rib, that’s what they’ll do. They’ll check for that immediately. But even if it’s bad,  a broken rib, if it’s not displaced or causing complications, it should self-heal. But what if you have two broken ribs? You don’t know whether it’s going to self-heal, and you don’t know whether it’s something more serious.

So, you’re left guessing. It could be your lungs, it could be a muscle pull, it could be something minor—or it could be something serious,  cancer. But in a traditional system, you’re told, “Your next appointment is in four months. Can’t wait that long? We might call you if something opens up.” So, you wait. Maybe you get better, maybe you get worse.

By the time you finally see the doctor, it’s been months.

Jacobsen: And that’s your typical insurance-covered visit, right?

Misra:  With Direct Primary Care (DPC), it’s different. You have a membership, and when you’re not feeling  you can text or email your doctor and ask to be seen that day. You can say, “I’ve got some side pain; I might have a broken rib. What do you think?” Your doctor gives you a requisition form for an X-ray, which might cost $25, schedules the appointment, and follows up the next day or so—done. Mic drop. That’s the difference.

Jacobsen: What are the critiques of DPC, and how are insurance companies responding to these criticisms?

Misra: There are challenges, especially with Medicare-age patients. Medicare covers certain services, and they won’t allow you to go outside that coverage. That’s what Medicare Advantage plans are for, but the reimbursements for those plans and traditional Medicare are complicated.

All of this complexity is intentional—it’s confusing, so people don’t ask questions. But Medicare doesn’t allow you to opt out of its system. With DPC, we’re trying to emphasize that we’re not insurance, but policy changes are still needed.

Misra: I  to say we’re “assurance” instead of insurance. You’ll see your doctor—that’s my plan. However, Medicare and Medicaid can be problematic because they’re government-run systems, and a systemized system doesn’t allow you to go outside.

Why? Because they want to save money and keep everything within the business. Medicare is an issue, but we have hybrid programs, and there are ways around it. Medicaid can also be challenging.

Catastrophic care coverage can help lower your premiums if you have catastrophic emergencies,  a motor vehicle accident or cancer. We’re addressing many of the problematic questions as we go along. it’s not a direct primary care movement; there’s also a direct specialty care movement happening alongside it.

Specialists are now leaving hospitals and realizing, “Hey, the patient can pay me $2,000 directly instead of the hospital charging $10,000 and reimbursing me only $1,000.” All you need to do is ask your doctor, “How much will that procedure cost out of pocket?” Whether it’s surgery, giving birth, or getting a vasectomy—how much will it cost? One of my favourite examples is colonoscopies. They’ll cover the colonoscopy but not the anesthesia. Who’s going to get a colonoscopy without anesthesia? 

Jacobsen: No way.

But that’s how it works. In some places, they’ll cover the colonoscopy, but your deductible for anesthesia might be $2,500. you’re thinking, “I’m not doing that.” But what if I told you I could get the colonoscopy and anesthesia for $1,500?

Another issue is data protection, which is becoming increasingly important as A.I. advances and telemedicine becomes more common. COVID changed the playing field, so I emphasize data protection. Cyberattacks are on the rise, and keeping patient data secure is critical. Even my dentist had special training in encrypting and securing patient files.

Most of us use secure electronic medical record (EMR) systems. For example, my EMR uses Google, and it’s HIPAA compliant. It has telemedicine built in, and I can text patients through it while staying HIPAA compliant. Everything stays within the system. There are ways to stay compliant, and you also need cyberattack insurance. That’s another reason medicine is expensive.

That’s why companies  Amazon and Walmart, when they tried to get into healthcare, eventually shut down their medical divisions. They realized “Primary care is hard.”

Jacobsen: Regarding direct primary care, what else happened with COVID?

Misra: COVID-19 damaged the patient-doctor relationship. The little trust that we had was destroyed. A lot of patients are now comfortable with telemedicine. My approach is to always meet the patient where they are. Some patients still need to go to a doctor in person, which is as close as they want. Others might turn to a national telemedicine company for partial treatment. I’ve worked with several companies, and they need more in what they can do.

It’s frustrating because, for instance, I might be treating someone with testosterone therapy. If it leads to hypertension, I can’t treat the hypertension within that system. It’s frustrating for both the patient and me. Essentially, you’re not getting complete care. You get partial care, and then they tell you to see your primary care doctor. Direct primary care (DPC) doesn’t operate that way. I might be treating someone for men’s health, but if I notice their blood pressure rising, I’ll address it. If it’s not included in their membership, we can modify the membership to include it. This is because some integrated medicine and DPC aren’t covered by insurance, and patients pay out of pocket. Kaiser, for example, doesn’t cover these services, and certain insurance plans won’t either. Unless you’re seeing an endocrinologist, many doctors won’t address it.

In direct primary care, we can manage these additional needs. For instance, I had a patient I was treating for one issue today, but we encountered a potential emergency. This patient was too scared to go to the hospital, partly because they knew they might no longer see a doctor at the E.R. Many must realize that ERs are separate, for-profit entities, even though they’re affiliated with hospitals. Their main concern is only sometimes providing the best treatment for the patient. The decision to admit someone to the hospital is also often handled separately. The E.R. and the hospital are part of a different system, and they shouldn’t really be tied together because of the financial conflict of interest.

A lot of ethically questionable things happen in this system. When you go to the E.R., you might not see a doctor, as many doctors are leaving E.R. medicine for direct primary care, aesthetics, or other fields. Patients are still determining what will happen or whether they should go to urgent care instead.

The patient had an urgent issue beyond my management scope in this case. They were in a different location than usual, so I was trying to arrange for imaging. Knowing those options ‘ limitations and potential costs, the patient wanted to avoid going to urgent care or the ER. But because we’ve built a relationship of trust through direct primary care, they were willing to meet me halfway and agree to imaging. I coordinated the imaging and potential emergency room care in case the results were concerning.

This level of care coordination is only possible with non-direct primary care. In other systems, patients are often sent to the ER and discharged without follow-up or communication. That’s not how direct primary care works.

Today, I had a typical case in DPC with an insurance patient. Still, their insurance is limited to a specific healthcare system, and I’m outside of that system. We could only use the insurance for imaging if the patient went to that system’s E.R. Even if they went to urgent care, there’s no guarantee they’d get the necessary imaging. Often, patients are sent to the E.R. anyway after paying the urgent care fee because the urgent care center can’t handle it.

DPC doctors can help triage whether a patient needs urgent care or an E.R. visit, saving time and frustration. This is one of the benefits of DPC, and it’s why I do what I do. I don’t accept insurance, but I advised this patient to ask about the out-of-pocket costs for the imaging. Initially, they wouldn’t tell me, but we eventually got the information after my nurse followed up.

So they told me the out-of-pocket cost. The out-of-pocket cost might be less than their deductible if they pay with insurance. The crazy part was that the appointment for my stat order was scheduled two weeks from now. It was a stat order, and they gave an appointment two weeks later.

What if something serious happens, like the patient dropping dead? It’s incredibly frustrating. So I had to call in and emphasize that it’s a stat. It’s stat because if something is found, we’ll need to send the patient to the E.R. I’m coordinating all that.

It’s maddening. But because I intervened, this patient is now going to be seen. I was supposed to see this patient, but that appointment opened up since they’ll now be going for imaging. I’ll see them later if needed.

Earlier in the response, interest was raised about cultural issues affecting both doctors and, more importantly, patients. The trust level has dropped post-COVID. Before COVID, doctors weren’t at the highest risk for suicide. But now, we are. 

Regarding the social factor of trust, I’ve had my doctor appointments where we discussed how bad things have become. We’re all pulling our hair out, asking, “What do we do?” What will eventually happen is that doctors will leave the system and create their own. Patients will be left with nonphysician practitioners.

You’re not seeing doctors anymore, but you’re being charged as if you are. 

Jacobsen: Is this a consequence of the long-term privatization of healthcare? 

Misra: It’s a consequence of insurance companies having too much power. It’s a consequence of the corporate takeover of medicine. It’s a consequence of venture capitalism putting profits over patients.

Healthcare can’t operate like other industries—it is expensive, and doctors have to triage care and money. There’s an order of operations. Medicine has reached this point because it used to be the opposite—too free. Insurance. Insurance and the government stepped in to say, “No, this is what things should cost,” because of perceived price gouging by the medical field.

So instead, they started price gouging. There has to be a balance between this and where we are now. I’m not saying direct primary care is the answer. It’s an answer for some of us right now, and so is direct specialty care, which is a parallel movement. But back to the original point—trust.

Jacobsen: When there’s pervasive distrust, several questions come up as subtext. First, why? What factors preceded this level of distrust, leading to high levels of mistrust that were then exacerbated by COVID, which resulted in virtually no trust? When did the trust start failing?

Misra: I know when I started noticing a shift around 2014 or 2015.

It might have started even earlier. My mom passed away in 2010, and I was heavy in grief at the time, so I wasn’t paying close attention to these shifts. I was shrouded in a cloud. However, my colleagues noted that direct primary care (DPC) had emerged before that in rural America, showing there was already a need to break away from administrative encroachment.

When too many people are involved in something that’s supposed to be an intimate, collaborative experience, it becomes chaotic. Everyone starts saying, “Where’s my piece? My piece needs to be bigger.” Meanwhile, the patient is hemorrhaging, and the physician is desperately trying to stop the bleeding. It’s a problem when you try to monetize something that involves ethics and integrity. If we don’t consider that, physicians may start charging fees comparable to those of attorneys because the level of thought and care we provide is immense.

When did trust break? It happened when doctors stopped being respected. Corporations and insurance companies started thinking, “What doctors do is easy, and we can get others to do it for less.” That mentality set in, and then COVID-19 exposed those cracks. It was already a problem before the pandemic, but COVID-19 has worsened. And we could have handled it better. We handled it at all.

I thought it was just a different version of the flu. We didn’t know what it was and still needed to understand it fully. We’re living with it now. During that time, even doctors were struggling. We had these masks, and doctors would say, “My PPE is broken, it’s ripped.” Maybe a hypoxic patient grabbed at your face, and suddenly you’re exposed. I can tell you how we used to handle breathing apparatuses before COVID-19, but that’s likely gone now.

We used to do fit testing. When we entered a room with a T.B. patient, you weren’t allowed in if you didn’t have a complete seal around your mouth. That went out the window with COVID, which was highly contagious, just like T.B. But T.B. is deadly, and so was COVID. We couldn’t maintain those standards anymore. You might have had one or two negative pressure rooms in the hospital.

We couldn’t even take care of ourselves, let alone our patients. And patients noticed. They could tell that we didn’t know what was going on. That bred more distrust. Then we imposed all these restrictions, telling people not to move or do anything. And whenever we did have to move or respond to something, there was chaos. People got angry and protested en masse, and then COVID surged again. We didn’t handle it well as a society or as a government. It was a horrible time, and we’re still living through it. We’re traumatized by it, and we’re sitting in that trauma right now. There’s so much we could discuss about this.

Jacobsen: So, what are the standard critiques of direct primary care (DPC)? What do you hear from patients or insurance companies?

The hardest part is convincing people that we provide better care because we’re less restricted. It’s a market challenge, but once people experience it, they don’t return. They don’t.

I educate through a platform called VuMedi. It’s a national physician education platform, and my channel focuses on direct primary care and medical innovations. Direct primary care allows me the time to explore these innovations. You were asking something—what was it? Oh, criticisms. Yes, right.

So, I don’t want to name names, but I’ll explain the context. The person who gave me this opportunity—I don’t get paid for it; it’s free for physicians because it’s an educational platform to share knowledge—was initially skeptical. They didn’t get it but saw I was passionate about it, so they gave me a channel and said, “Let’s film it a couple of times and see what happens.”

Then, this person attended a conference or health fair and saw not just one but two or three direct primary care doctors there. They realized, “Oh, this is what she’s talking about. She’s not some crazy woman I gave a channel to.” After that, this person tried to make an appointment with their doctor because they weren’t feeling well—whether it was an annual check-up or something else.

The next available appointment was in October, and the following was in December. They remembered what I had said about direct primary care and signed up with a DPC doctor within a month—all in two weeks.

The difference is this: You call to make an appointment with your regular doctor, and it’s all about whether your insurance is current. “Did you pay for everything? The doctor isn’t available until January, but your insurance might change by then, so you’ll have to call back.” By the end of it, you haven’t accomplished anything.

Now, with DPC, you can text your doctor directly. “Hey, my throat hurts. I don’t feel well.” Your doctor can respond, “I can do a virtual appointment today at 4, or see you tomorrow, or maybe get an X-ray and then follow up.” That’s a plan.

That’s the difference. With DPC, you’re paying for access, experience, and more personalized care. And since the movement is growing, we are still determining where it will take us.

Direct specialty care has now become an analogous revolution, a movement. It’s pretty cool. 

Jacobsen: What are the reasons for people who leave direct primary care and return to another or the traditional system?

Misra: Oh gosh. It’s because being an entrepreneur takes work. Being a “doctorpreneur” is even harder because we aren’t taught business skills. Asking for money while providing medical care—doesn’t come naturally to us. It’s hard for doctors to say, “If someone is dying on the floor, we’ll help—but only after they pay us $100,000.” That’s how most of the world works, but it isn’t easy for us. So, you have to be passionate about what you’re doing.

Direct primary care is sometimes a stopover before people leave medicine entirely. I say that all the time. Direct primary care can be a transitional phase for people who realize, “I tried it, but I don’t like it.” They may prefer the traditional system where things are fed to them, and they do what they must, even though it’s abusive. When you’ve been abused, it’s sometimes easier to stay in that system because it’s familiar. That’s basic psychology. It takes work for people to leave.

It’s hard to leave a pioneering, revolutionary space. Convincing people to become your patients and building a patient base in a system that’s yet to be the norm is also difficult. Yes, some people need to improve in direct primary care and close their practices. But many are thriving, making seven or eight figures.

Jacobsen: What’s a DPC Dino?

Misra: We call them DPC Dinosaurs because they’re dinosaurs pretending to be direct primary care. Think of companies like One Medical and Parsley Health. They’re big names, and they ride the direct primary care wave. But real DPC is when the doctor enters the room and already knows how your wife is and what’s going on in your life because we’re in such frequent contact that we know our patients on a personal level.

In traditional healthcare, the doctor might walk in and say, “So, this is what’s going on with your cancer,” and the patient is like, “What cancer? No one told me I have cancer!” I hate being that kind of doctor.

Jacobsen: What about the risks of inaccessibility for low-income patients? And what about the potential for cherry-picking patients?

Misra: That’s a valid concern. However, many direct primary care doctors charge less than $100 monthly and offer service exchanges because we are free of insurance constraints. For example, patients can pay with eggs, steak, or even a gym membership. This bartering system is popular, especially in rural America, where direct primary care first took root.

We serve underprivileged communities. We work with uninsured patients because we want to lower costs. I’m constantly negotiating prices. Part of the reason I have my educational channel is to bring people on and say, “Hey, here’s free exposure for you, but can you offer a discount or a code to make things more affordable for the DPC movement?” That’s part of what I do.

We also have GPOs—group purchasing organizations—to save money. Who doesn’t want to save money? Even if you want to pay $5,000 monthly, you can get a concierge DPC doctor at that rate.

Jacobsen: You mentioned the movement is growing, but it still needs to be determined as more doctors shift to direct care. At the same time, the traditional healthcare system in the U.S. needs help with retention and recruitment. Long-term, that’s unsustainable. What about scalability?

Misra: Yes, scalability is a major issue. The U.K. is facing significant problems, too. We’re in a strange phase where direct primary care is growing, but so is the overall instability in American medicine. It will be challenging to scale DPC to meet the growing demand while maintaining its core principles.

I love DPC because we always advocate for not having people spend much money. We discuss financial freedom and how much money you should spend before starting your practice. I advise against buying all the tools and toys right away. Start small and use what you have here and here. I did a video on this again: use your brain, your heart, your mouth, your prescription availability, and your physical exam skills. That’s what we want.

Jacobsen: What about the variability in quality? Are there issues with quality assurance for each doctor?

Misra: That’s an issue with every doctor you go to, and it’s probably worse with the insurance system. Quality improves with DPC because many DPC doctors offer meet-and-greets. You can talk to the doctor and decide if they’re right for you. If they’re not, you save your time. But if you click with them, you say, “I like this doctor; I want to work with them.”

Jacobsen: What about regulatory and legal uncertainty?

Misra: You said it—it’s uncertain. We’re working on some policy initiatives. I wrote something in A.I. recently and was asked, “What’s happening with DPC policy right now?” I answered, “It’s too soon; we need data.” So, in my video, I made a call to action: “Hi, we need data.”

Jacobsen: What about the exclusion of employer-sponsored financing?

Misra: It’s interesting because large-scale employers are recognizing the savings. Ernst & Young, Prudential, and other health insurance companies, like Blue Shield, are partnering with DPC doctors to get better care for their employees. What does that tell you? They’re seeing the savings and benefits of going directly to the doctor.

Jacobsen: Could it also be that if you aren’t up to snuff, you could be out of business quickly? Your patients will only stick around if you meet a certain quality standard.

Misra: Yes, and that’s a real concern. I have some pretty healthy patients now who are thinking about leaving, but they know they’ll need care eventually. It’s like this: you’re paying for access. Are you going to leave Costco?

Jacobsen: Depends on what I need.

Misra: Exactly. It depends on what you need. But your DPC doctor can handle most of what you need, even if you don’t know what you’ll need in the future. We can predict some of what you need every few years.

Jacobsen: What’s the hardest part of being a docto? You’ve started your own business and made the transition to DPC. What’s been the toughest part?

Misra: The hardest part of being a doctor is staying a doctor right now. I mean that with all my heart. Every day is a struggle because it’s heartbreaking. My colleagues are suffering. I had my own doctor’s appointment early this morning, and my doctor had to cut it short because they had to attend a funeral. One of our colleagues died—killed themselves. It’s happening so often. And not only are doctors dying from suicide but some are being murdered, too.

I had someone at a meet-and-greet who said, “I have ADHD, and I need my ADHD meds.” My response was, “I don’t prescribe ADHD meds for certain patients because I once had a knife to my throat.”

Jacobsen: The United States has a culture of scientific ignorance, especially considering its wealth and access to high-end education. It’s a weird paradox. Absolutely, and this paradox was pointed out a long time ago by Carl Sagan and others in the scientific skeptic and humanist communities. A consequence of this ignorance is that when individuals experience a negative outcome, which can happen occasionally even with the best care, they look for someone to blame. Psychologically, it’s a defence mechanism, so they blame the doctor.

Yes, for instance, they take too much Tylenol, their blood thins, they faint, and then they blame the doctor. It’s a complete mix-up of cause and effect—or at least the chain of events. And yes, in tragic cases, it’s very real. It’s not like watching House MD get shot on T.V.; this happens in real life.

Misra: Something I always say about weight loss treatments fits into this dichotomy. We, as doctors, know that we’re the first generation dealing with a large population of obese individuals who are both micronutrient and macronutrient deficient. What’s in our food? What are we doing?

That’s part of the paradox. When discussing lean muscle mass loss with medications like Wegovy or Ozempic, the real question is: What patient population are we starting with? Many of these patients don’t have much muscle to begin with, and on top of that, they’re eating less. We’re already dealing with micronutrient-deficient patients, and now they’re losing even more nutrients by consuming less. Of course, they’ll lose lean muscle mass—they’re losing everything.

This is why the craze with med spas, compounding, and trends like Ozempic is so frustrating. We, as doctors, know better, just like how people misuse Ivermectin or other off-label treatments.

Ozempic became a huge trend. Everyone started taking it, even though it’s intended for type 2 diabetes. Ozempic is for type 2 diabetes, but the dosage doesn’t go up to the levels used for obesity anymore. They’ve changed it, and now insurance companies are asking for their money back if patients took Ozempic for non-diabetic reasons. Insurance companies send emails saying, “We need our money back because you took it for the wrong indication.”

Jacobsen: Do you want to dig into anything further? I need more help diving deeper because we’re venturing into territory where my non-expert view would lead to wrong assumptions. So I’ll leave it at that. Out of everything we’ve discussed, what do you think needs to be said but has yet to be voiced, especially on platforms that don’t typically allow for such honesty about the current state of doctors?

Misra: We are suicidal. We are leaving medicine. If you can’t find a doctor, it’s because there are fewer of us left. I will say this kindly: you must be kind to your doctor. We’re trying to be professional, but you don’t know what’s happening behind the scenes. Medicine is complicated, and your insurance’s explanation of benefits intentionally confuses doctors and patients.

When angry about your insurance, take it out on them instead of your doctor. You negotiated that insurance; you chose it. We didn’t. We want to work for you and be better for you.

Here’s another thing: many doctors have out-of-pocket costs cheaper than you pay for insurance. Insurance is racketeering—I’m going to say it. Whether I want that published or not, it’s the truth. It’s fearmongering, and it’s getting worse. Insurance companies are committing medical fraud by denying care. When a doctor prescribes something with clear medical justification backed by evidence, that prescription should be honoured. By denying it, patients are suffering and even dying.

This situation creates a moral injury for doctors. We are burning out because we constantly battle a system that denies care. It’s not that we don’t want to help—there may be bad doctors, but many of us are doing our best. We’re part of the problem, but the system is breaking. People don’t realize how bad it is because we keep up a professional front until we die. This is a crisis, and it needs urgent attention.

Jacobsen: Thank you.

Misra: Thank you for making time for me and for listening. I appreciate it.

Jacobsen: You’re welcome. So, goodbye from Canada, and have a good day. Enjoy the weather. It’s been raining the last few days, but hopefully, it’s not too bad where you are.

Misra: It’s pretty hot here. Honestly, there’s no place with perfect weather right now.

Jacobsen: Iceland. Iceland is a good option. 

Misra: I’ve heard great things, but I have yet to be.

Jacobsen: New Mexico is too hot for me. I’m too fair-skinned.

Misra: Same here. I even burn where I am now, so I’m staying put.

Jacobsen: Sulgana, thank you so much. I appreciate it.

Misra: You’re welcome. Bye!

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