Dear Members,

Since earning my medical degree and pledging to uphold the code of the Hippocratic Oath in 1999, I have been flooded, flayed, buffeted, and gobsmacked by a sequence of events involving the patients who had entrusted their care to me.  I call them my existential crises.  They mark a series of awakenings to various intrinsic aspects of the system that I had become a part of, like a cog in a wheel, but which I found to be irreconcilable.  These aspects simply could not be excused away or justified.  They initially had a mind-numbing effect upon me.  Eventually they broke my heart, just as I believe similar events and observations break the hearts of so many caring, dedicated, passionate human beings who enter our profession with bright eyes—only to become disillusioned, dispirited, demoralized, and jaded practitioners of modern medicine.

In ever increasing numbers, more and more of us bear witness to the great unacknowledged grief of our profession.  As in most cases, the grief moves through us in the stages that Elizabeth Kubler-Ross so neatly lays out in her work.  The initial stages are marked by disbelief and denial.  Then we move through anger, which eventually turns into a deep sadness, and finally (as we begin to heal) acceptance and integration of the grief which empowers and enables us to move forward again.  I believe many of us in the medical field are currently stuck somewhere in the middle—alternating between disorientation, infuriation, and despair.

Martín Prechtel wisely teaches us that “grief” is just another name for “praise”, and that our heartbreak is an indication of how much we care deep down, of how much we love.  The grief we accumulate by working and participating in a system that is both wondrous and unjust, both miraculous and insane, both relieving of suffering and itself so causative of suffering is commensurate with our capacity to imagine a better system and to believe (to the core of our being) that such a system is possible.

When we are able to embody our praise, to sing and laugh and yell with gratitude for all of the blessings in our lives—for the gift of simply being alive—we can learn to accept our own failings, our human limitations, our vulnerabilities and mistakes, as well as those of our parents, ancestors, and culture.  From such an energetic state of appreciation and forgiveness, we can transmute our present and very real grief into newly discovered capacities and aptitudes which may give rise to unexpected insights, and possibly (with a lot of luck, good timing, and grace) lead to transformational action.

In my own experience, I feel as though my grief and heartbreak caused my heart to actually break open to new possibilities.  From the 10 heartbreaks came the 10 core principles of our practice, Cloud Medical.

Ultimately, we are all in this together and are co-invested in a healthy future for our children, their children, and our planet.  We welcome critiques in the spirit of continuous refinement.  What resonates with me most is the idea of collective intelligence rather than group think.  I believe we need less consensus panels and echo-chambers, and more micro-experiments, prototypes, and idea labs integrated into collaborative networks.  I believe in the principle of “I don’t know, but we know”.  And I believe that it really is possible to “remember the future”.

The kind of future that I “remember” enjoys and benefits from a healthcare system which not only incorporates the 10 core principles summarized below (and which are described in more detail later), but which is also imbued with two central values that were originally present in the indigenous healing traditions, yet have become lost or discarded along the way:  A nuanced and multifaceted understanding of healing, as well as a reverent devotion to our patients’ best interests.

I believe that we can’t move forward without bringing those values back.

The 10

Heartbreaks

Cloud Medical Core Principles

1. The US healthcare system is the #1 cause of bankruptcy.

PAYMENT

We must lead toward drastic reduction of our national healthcare costs.   Direct Primary Care (DPC) is the most promising innovation capable of meaningfully bending down the cost curve.  Combined with a healthshare program, most individuals, families, and businesses can save approximately 50% on their total monthly healthcare spend.  This model is available nationwide today.
2. The US healthcare system is the 3rd leading cause of death.

PRACTICE

We must reorient from a purely pathogenic sick-care model based on synthetic pharmaceuticals and surgery as our only tools toward a model that incorporates salutogenic principles.  The purely pathogenic model is FAR too dangerous.  Functional integrative medicine and naturopathy are better at seeking “source causes” rather than bandaid approaches.  A growing number of PCPs (Primary Care Physicians) are being trained in functional medicine by the IFM, A4M and similar organizations.  This is an excellent start.
3. We allow, enable, and are complicit in rampant conflict of interest and perverse incentives.

PROFIT

We must stop conflating “prescribing” with “selling”.  They are very different!  DPC physicians receive adequate payment from their patients ($80 per member per month provides a more than reasonable salary) so that NO additional selling and marking-up of tests, supplements, drugs, or therapies for profit is necessary whatsoever.  All such products and services (including diagnostics, medications, supplements, etc.) can be provided at net-zero profit.
4. We often withhold power from our patients.

POWER

Our major goal should be, plainly stated, “Patient Empowerment”.  We must retire the pretentious and outdated paternalistic approach of “doctors know best.”  By getting to know our patients as human beings with their own values and aspirations, and embracing humility for how little we actually do know, we can help orient our care to support them on their own terms.
5. We often devalue and discount the innate healing capacity of our patients.

POTENTIAL

Physicians who tell their patients that “they will never walk again” effectively “curse” their patients, similar to voodoo.  They are imposing their own limited views which are not based on fact.  This happens far too often and there are myriad examples  (e.g. Lance Armstrong was initially told he would “never bike again” upon his testicular cancer diagnosis).
6. We often poorly rank risk/benefit and cost/benefit ratios, and discount various biases inherent in publications.

PRECISION

There are certain interventions that have very high benefit at very low risk.  But many of our drugs have marginally beneficial effects, with significant potential for adverse effects.  We must always advocate for our patients and help them select the safest and most cost-effective treatment options.  If you believe that “we already practice that way,” please read #1 & #2 above.
7. We tolerate a lack of systemic transparency.

PERSPICUITY

The healthcare system operates behind a massive Wizard of Oz screen.  This is a key problem that enables bad behavior and fraud.  We should never prescribe a test or a therapy without knowing the cost—to the penny—and share this information freely.
8. Our patient privacy laws protect the wrong parties.

PRIVACY

HIPAA may protect a patient from snooping neighbors and passers-by, and while this is appropriate, there is no protection against insurance companies and governmental agencies.  Doctors should help their patients shield sensitive data from such large entities.  If sensitive data is to be shared, it should be anonymized, consented, and the patient should be compensated.
9. We are far too beholden to special interest groups.

PERSONAL FREEDOM

Most medical consensus panels are composed of “experts” who are paid large sums by pharmaceutical and other for-profit companies, and many are employed by hospitals whose incentives may not line up with our patients’ best interests.  The independent direct primary care physician is the rare healthcare guide who is not beholden to or biased by special interests.
10. Our system is vampiric and the “healers” have lost faith in our own profession.

PASSION FOR MEDICINE

When the “healers” are disillusioned, jaded, and have unexpressed heartbreaks about systemic dysfunctions (such as the ones noted above) the transmission to our patients can be neither salutogenic nor eudaimonic.  We must be intellectually honest and define the true causes of why our profession is so broken.  The politicians won’t fix them because  a.) they don’t know how, and  b.) they are too entangled with special interest groups.  Who is left to lead the way toward a sane and ethical system if not us?