When patients walk through the doors of the Surgery Center of Oklahoma, they often bring stories of frustration, fear, and financial devastation from their encounters with America’s health care system. Yet, what they find in Oklahoma City is radically different: a transparent, patient-centered surgical experience at a fraction of the cost of most hospitals and surgery centers.

At the heart of this revolution is Keith Smith, M.D. , an anesthesiologist and co-founder of the Surgery Center of Oklahoma. His model has become a beacon for patients and an inspiration for physicians, proving that health care can be both affordable and high quality—if physicians are willing to step outside of the traditional third-party payer system.

I had the privilege of speaking with Smith for the Medical Economics podcast Physicians Taking Back Medicine. For me, the conversation was not only professionally inspiring but also deeply personal. As a family physician, I’ve referred my own patients across the country to Oklahoma for surgeries they could not afford locally.

One of my patients without health insurance was quoted $20,000 at a local hospital for a life-saving surgery—so expensive he needed to sell his Harley-Davidson motorcycle to pay for it. Instead, he flew to Oklahoma, where he underwent surgery for under $5,000 (including travel and lodging), and returned home with his dignity, health, and savings intact.

That kind of story raises the obvious question: Why isn’t this model being replicated everywhere?

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Patient Frustrations and Introduction to Keith Smith, M.D. (00:00:14) Overview of patient struggles with the healthcare system and introduction to Keith Smith, M.D., and the Surgery Center of Oklahoma.

Smith’s Background and Motivation (00:00:54) Smith's early career, government payment frustrations, and decision to leave traditional hospital practice.

Founding the Surgery Center of Oklahoma (00:01:40) How Smith built his reputation, gathered colleagues, and started the surgery center to protect patients financially and medically.

Early 90s Healthcare Problems and Free Market Motivation (00:02:27) Declining quality of care, financial abuse by hospitals, and the decision to create a fair, market-driven alternative.

All-Inclusive Cash Pricing Model (00:04:02) Explanation of the center’s cash pricing, initial patient stories, and dramatic cost differences compared to hospitals.

Building the Price List and Industry Pushback (00:05:27) Development of a public price list, industry backlash, and the center’s role as a champion for affordable care.

Posting Prices Online and Market Impact (00:06:35) Decision to post prices online in 2009, attracting patients nationwide, and sparking a price war in healthcare.

Growth and Influence of the Surgery Center (00:07:42) Expansion to a larger facility, multi-specialty services, and inspiring other centers to adopt transparent pricing.

Patient Success Story and Website Usability (00:08:39) A patient’s experience using the website, cost savings, and positive outcomes compared to traditional hospitals.

Surgeon Compensation and Hospital Billing Disparities (00:09:55) Discussion of the vast difference between hospital charges and actual surgeon payments.

Market Creation and Price Matching (00:10:09) How public pricing led to market competition, price matching by hospitals, and the creation of a healthcare marketplace.

Eliminating Middlemen and Keeping Prices Low (00:12:19) How removing hospital profit motives keeps surgery prices reasonable and benefits both patients and physicians.

Barriers for Surgeons Adopting the Model (00:12:38) Challenges and fears preventing more surgeons from leaving the traditional system for a free market approach.

Entrepreneurship and Payment Systems for Physicians (00:13:11) The need for confidence, entrepreneurship, and understanding payment logistics for physicians considering this model.

Atlas Billing Company and Free Market Medical Association (00:14:32) How Smith’s billing company and association help other physicians transition to cash-based or hybrid models.

Headwinds and Examples of Success (00:15:46) Real obstacles, government resistance, and examples of other centers successfully adopting the model.

Advice for Physicians Considering the Model (00:18:23) Practical steps for doctors: starting small, finding leadership, and considering relocation to more receptive areas.

Overcoming Inertia and Finding Opportunities (00:20:29) Discussion of geographic and systemic barriers, and strategies for launching a physician-owned center.

Risks of Insurance Contracts and Going Independent (00:22:14) Risks of working with insurance companies, benefits of independence, and advice to leave government payments.

Economic Principles and Physician Value (00:23:44) Understanding value from an economic perspective and the importance of seeing value through the patient’s eyes.

The Free Market Model as a Positive Alternative (00:25:03) The benefits of the free market approach for physicians and patients, and encouragement to explore the model.

Closing Remarks (00:25:54) Host’s closing comments and invitation to future episodes.

Fifteen years ago, family physician Lee Gross, MD, was running a small private practice in southwest Florida and struggling to stay afloat. Reimbursements were declining, administrative costs were rising, and Medicare requirements grew more burdensome each year. The turning point came when a small business owner approached him with an unusual proposal: since all the employees already saw Gross as their doctor, why not pay him directly to take care of them?

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Introduction to DPC and Rural Health care Crisis (00:00:14) Overview of DPC, recent policy changes, and the episode’s focus on rural health care and DPC.

Dr. Lee Gross’s Background and Early Practice Challenges (00:00:52) Dr. Gross describes his medical background, move to Florida, and frustrations with traditional practice.

Electronic Medical Records and Medicare Barriers (00:01:53) Early adoption of EMR, government regulations, and financial penalties from Medicare.

Medicare Payment Cuts and Practice Sustainability (00:02:47) Struggles with declining reimbursements, attempts to find alternative revenue, and the unsustainable fee-for-service model.

Epiphany: Transition to Direct Primary Care (00:03:47) Realization that insuring primary care is inefficient; inspiration to start a subscription-based DPC model.

DPC Business Model Details (00:04:50) Explanation of DPC pricing, services, and the elimination of third-party billing.

DPC in Rural Florida: Practice Viability (00:05:22) Challenges of rural practice, patient volume, and how DPC enables sustainability with fewer patients.

DPC as a Rural Health care Solution (00:06:28) Discussion on why DPC fits rural areas and legislative efforts to promote it.

Telemedicine vs. DPC in Rural Settings (00:07:09) Limitations of telemedicine alone and the value of continuity with a known primary care doctor.

Cost Comparison: DPC vs. Federally Qualified Health Centers (00:08:57) Senate testimony on DPC’s cost-effectiveness and the administrative overhead of traditional models.

Introduction of Rural DPC Physicians (00:10:18) Transition to interviews with three rural DPC physicians.

Dr. Lee Gillum’s Background and DPC Journey (00:10:24) Dr. Gillum’s return to rural Tennessee, dissatisfaction with traditional practice, and switch to DPC.

Impact of DPC on Rural Community (00:11:45) How DPC has improved access for uninsured and underserved patients in rural areas.

DPC and Rural Practice Sustainability (00:12:33) Challenges for small practices, Medicaid/Medicare reimbursement, and how DPC enables survival.

Dr. Nehemiah Weimar: DPC in Rural Indiana (00:13:35) Dr. Weimar’s pediatric DPC practice, local hospital closures, and the importance of time in patient care.

Dr. Katie Worden Greer: DPC in Rural Oklahoma (00:15:19) Dr. Greer’s background, transition from tribal health to DPC, and building a practice in a small town.

Medicare Opt-Out Dilemma for DPC Doctors (00:16:51) Explanation of Medicare opt-out rules and the catch-22 for rural DPC physicians needing supplemental income.

Dr. Lee Gross on Medicare Opt-Out Policy (00:17:56) Gross discusses the risks and advocacy efforts to change Medicare opt-out requirements for DPC.

Dr. Lee Gillum on Medicare Challenges (00:19:25) Gillum shares his hybrid practice, difficulties with Medicare, and the impact on patient care and finances.

Administrative Burdens of Medicare (00:21:00) Discussion of data submission requirements, reduced payments, and the impact on small practices.

Balancing DPC and Community Roles (00:23:14) How DPC allows flexibility for rural doctors to serve multiple community roles.

DPC’s Role in Rebuilding Trust in Rural Health care (00:24:24) Importance of time and trust in rural communities, and how DPC addresses these needs.

Advice for Starting DPC in Rural Areas (00:25:25) Dr. Greer encourages physicians to consider DPC in rural settings and explains patient acceptance.

Future of Direct Care Model (00:26:31) Dr. Gross reflects on DPC’s growth, its challenges, and the hope it offers for younger physicians.

Podcast Conclusion (00:28:40) Host wraps up the episode, summarizing the stories and mission of the podcast.

“They need to just suck it up, buttercup.” That’s what an insurance executive told physicians who asked why the system was burning them out. For many physicians, that attitude is the last straw.

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Introduction and Dr. Wilbur’s Background (00:00:15) Dr. Wilbur shares her journey leaving clinical care due to systemic barriers in healthcare and her motivation to seek change.

Systemic Problems and Physician Powerlessness (00:01:20) Discussion of systemic issues, lack of autonomy, and the inability of physicians to provide optimal care within current structures.

Qualitative Research and Book Genesis (00:02:32) Dr. Wilbur explains her qualitative research interviewing physicians leaving medicine, leading to her book "The Doctor Is No Longer In."

Physician Debt and Misconceptions (00:04:27) Addressing the misconception that society pays for physician training and the reality of massive medical school debt.

Collapse of the Healthcare System (00:06:14) Rising physician attrition, suicide, and predictions of healthcare system collapse due to neglecting core resources.

Patient and Physician Suffering; Greed in Healthcare (00:08:04) Exploring shared suffering of patients and physicians, and the impact of greed at multiple levels in healthcare.

Physician Employment and Loss of Autonomy (00:09:12) Shift from independent practice to physician employment, and the resulting loss of decision-making power for doctors.

Anecdote: Dr. Guy Clifton and Patient Safety (00:09:43) Story of a neurosurgeon advocating for patient safety, resistance from administration, and the power of physician integrity.

Moral Injury and Physician Suicide (00:12:14) Defining moral injury, the existential crisis for physicians, and factors distinguishing those who leave from those lost to suicide.

Messages of Hope and Community (00:14:37) Encouragement for physicians facing moral injury, the importance of community, and resources for support.

Making Noise and the Documentary (00:16:16) The need for advocacy, public awareness, and the transition from book to documentary to amplify all stakeholder voices.

Dr. Todd Otton's Story and Documentary Origins (00:17:21) Dr. Otton’s experience with burnout, meeting Dr. Wilbur, and the inception of the documentary project.

Meaning Behind “Suck It Up, Buttercup” (00:18:42) Origin of the documentary’s title from both physician training and insurance executive attitudes.

Documentary Goals: Impact and Network (00:19:33) Aims to combat learned helplessness, inspire hope, and create a network of healthcare change agents.

Diverse Voices in the Documentary (00:21:12) Highlighting the inclusion of physicians, nurses, patients, and advocates in the documentary.

Funding, Timeline, and Distribution Plans (00:21:49) Progress on funding, expected completion, and plans to reach a wide audience via streaming platforms.

Ongoing Call to Action and Systemic Barriers (00:22:56) Vision for continuous calls to action, the entrenched status quo, and the urgent need for systemic change.

Personal Impact of Systemic Decisions (00:23:53) Dr. Otton’s personal story of burnout, the ripple effect of administrative decisions, and the cost of short-term thinking.

Connection, Support, and the Power of One (00:25:06) Emphasizing the importance of connection, mutual support among physicians, and the exponential impact of collaboration.

Podcast Conclusion (00:26:01) Host wraps up, highlighting the mission to share stories of physicians working to improve healthcare.

In this episode, host Dr. Rebekah Bernard explores whether maintenance-of-certification (MOC) requirements are quietly worsening the U.S. physician shortage. Retired rheumatologist Dr. Mark Lopatin recounts how escalating ABIM recertification demands—and their costs—pushed him to leave clinical medicine early. Neurologist Dr. Paul Mathew then explains how similar frustrations led him to help launch the National Board of Physicians and Surgeons (NBPAS), a low-cost, CME-based alternative to the American Board of Medical Specialties.

Mona Masood, DO and Nicole Washington, MD are psychiatrists who have long focused on physician wellness, founding resources to destigmatize and improve physician mental health. In 2020, Masood developed the Physician Support Line, a peer-to-peer network of volunteer psychiatrists offering free and confidential support to medical students and physicians. The line is available from 8 AM to midnight (ET) Monday through Friday. For physicians who need ongoing mental health care, Washington created Physician Mental Health, a directory of psychiatrists treating physicians. 

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Consider this scenario: You are having a medical emergency. An ambulance takes you to the nearest emergency department, where you are met by a nurse practitioner (NP) or physician assistant (PA), who may or may not have extra training in emergency care. You ask for a physician, but there are none in the department, or even in the hospital.  In fact, there isn’t even a physician available by telephone to guide the NP or PA in your care. 

In the first episode of Physicians Taking Back Medicine, host Rebekah Bernard, MD, discusses this important topic, with insights from fellow physicians Deborah Fletcher, MD, and Mercy Hylton, MD.

Lack of 24/7 Attending Physician Coverage in US Emergency Departments, 2022

Analysis of Nurse Practitioners’ Educational Preparation, Credentialing, and Scope of Practice in U.S. Emergency Departments - Journal of Nursing Regulation

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare: 

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Introduction to the Podcast (00:00:07)

Dr. Rebecca Bernard introduces the podcast and its focus on inspiring stories from physicians.

Dr. Debbie Fletcher and Dr. Mercy Hilton share their backgrounds in emergency medicine.

Discussion on the alarming trend of replacing physicians with non-physician practitioners in emergency departments.

Dr. Fletcher recounts her experience of being replaced by a nurse practitioner due to management decisions.

Dr. Hilton discusses the replacement of pediatricians with nurse practitioners during fluctuating emergency department volumes.

Concerns about inadequate supervision and care for patients by non-physician practitioners.

Dr. Hilton shares experiences of patient mismanagement and safety concerns in emergency care.

Dr. Fletcher agrees on the mismanagement issues observed, including overconfidence among non-physician practitioners.

Dr. Hilton discusses a concerning study on the educational preparation of nurse practitioners in emergency departments.

Discussion on the alarming findings regarding nurse practitioners' training and its implications for patient safety.

Dr. Fletcher initiates a workforce study to assess physician staffing in emergency departments.

Dr. Fletcher reveals alarming statistics about emergency departments lacking 24/7 physician staffing.

Findings on the lack of two-way communication between non-physician staff and physicians in emergency departments.

Dr. Hilton shares her advocacy efforts leading to Indiana's law requiring physician presence in emergency departments.

Discussion of the tragic case that motivated Dr. Hilton's advocacy for patient safety in emergency care.

Dr. Hilton details the process of getting legislation passed to ensure physician presence in emergency departments.

Dr. Hilton discusses gathering data to support the need for physician staffing legislation.

Discussion on the importance of transparency in advertising emergency departments' staffing levels to patients.

Dr. Rebecca Bernard thanks the guests for their advocacy work and concludes the episode.