I read Zoe Crawford’s thoughtful KevinMD essay on the limitations of direct primary care (DPC) with great interest. Her frustration as a medically complex patient navigating a fragmented health care system will resonate with anyone who has struggled to obtain timely imaging, referrals, or specialty care. As a clinician who has spent a career thinking and writing about how health systems fail both patients and physicians, I agree with her on one essential point: No care model works equally well for everyone.

Where I part company with her argument is not in the experiences she describes (which are real and important) but in the conclusion she draws from them. In critiquing DPC, she implicitly treats it as equivalent to private-pay psychotherapy. That comparison is understandable, particularly coming from a psychotherapist who has successfully practiced outside insurance for many years. But it overlooks fundamental differences between how mental health care and medical care function in practice.

Psychotherapy vs. primary care

Psychotherapy is, by design, largely self-contained. Treatment occurs in the room, at a predictable cadence, with minimal reliance on external systems. There are no imaging studies to authorize, no lab tests to coordinate, no infusion centers to contact, and no specialty referrals that hinge on insurance approval. The therapist’s professional responsibility begins and ends primarily with the therapeutic encounter itself, apart from occasional crisis management.

Primary care medicine is different by design. Even in a DPC model, the physician practices within a larger medical system that remains overwhelmingly insurance-driven. A DPC physician may opt out of billing insurers, but their patients do not opt out of needing MRIs, laboratory testing, specialists, hospitals, durable medical equipment, or prescription drugs. Those downstream services almost always involve insurance authorization, documentation, and coordination. The administrative burden does not disappear; it is displaced. When patients experience delays, denials, or communication breakdowns, they are often encountering the limits of the surrounding system, not indifference or neglect by their DPC physician.

This distinction matters because it helps explain why frustrations that feel personal are often structural. When imaging centers call patients directly for clarifications, or when referrals stall for weeks, the failure point is rarely the physician’s willingness to advocate. It is the reality that DPC exists inside (not outside) the same fragmented insurance infrastructure that burdens every other model of medical care.

Complexity and utilization

Crawford also raises a legitimate concern about feeling like a “high utilizer” in a flat-fee system designed around relatively low monthly memberships and unlimited access. This discomfort reflects a real mismatch between patient complexity and practice design. But it is not unique to DPC, nor does it represent a lack of professionalism or compassion. Any flat-fee or subscription-based model struggles when utilization varies widely. This is true in medicine, mental health, fitness memberships, and virtually every service built on averaged demand. Medicine simply exposes the tension more quickly because needs are less predictable and consequences more immediate.

That variability also highlights another difference between disciplines: risk pooling. In psychotherapy, utilization tends to be relatively stable over time. In primary care, complexity can change abruptly; an abnormal test, a new diagnosis, or an unexpected hospitalization can radically alter care needs. Flat pricing models are inherently stressed by that unpredictability, regardless of intent.

Infrastructure and overhead

Crawford’s critique of low overhead in DPC practices also deserves careful attention. Keeping startup costs low can make DPC accessible to physicians leaving institutional practice, but infrastructure matters in medicine. Exam rooms, diagnostic equipment, trained staff, and care coordination all require capital. When a practice minimizes those elements to keep membership fees affordable, the scope of care inevitably narrows. This is not a moral failure or a bait-and-switch; it is an economic reality. Patients benefit most when practices are explicit about what they can reasonably provide in-house and what will require referral elsewhere.

Importantly, the consequences of those limits differ by discipline. In psychotherapy, constraints most often risk interruption, undertreatment, or reduced continuity. In primary care, constrained access or delayed diagnostics can translate into missed or late diagnoses. That difference in failure modes matters when comparing care models across fields. What feels like inconvenience in one domain can have very different clinical implications in another.

Fee-for-service considerations

Crawford suggests that fee-for-service practice may be more sustainable and less likely to generate resentment toward complex patients. That may be true in psychotherapy, where time maps cleanly onto service delivered. In medicine, however, traditional fee-for-service models have their own well-documented shortcomings: rushed visits, fragmented care, and incentives that reward volume rather than continuity. Many patients sought out DPC precisely because those systems failed to provide access, relationship, or time.

None of this is to argue that DPC is the right model for every patient or every physician. It is not. But neither is private-pay psychotherapy an appropriate template by which to judge it. Each model embeds trade-offs shaped by the nature of the work itself. Confusing those differences risks misdirecting both patient expectations and professional critique.

Crawford’s essay is valuable because it challenges uncritical enthusiasm for innovation. Where it risks overreach is in treating two fundamentally different care models as interchangeable. Direct primary care is not psychotherapy, and judging it as if it were obscures both its strengths and its limits. The more productive conversation is not whether DPC “works,” but for whom it works, under what conditions, and with what transparency. That kind of clarity serves patients and clinicians alike and is far more useful than pitting imperfect models against one another in an imperfect system.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine and the fictional series Real Medicine, Unreal Stories. His latest book, a novel, is Standard of Care: Medical Judgment on Trial.