My blogging output has been at an all-time low since moving to Europe. Who knows why…this place is such a bore. I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.
The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine. It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States. In my email reply to him, I found myself writing my own little manifesto on the subject. A treatise, if you will. A declaration. A primer? A resolution, a promulgation…
I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms. Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries. So the idea isn’t new. It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen. It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans. I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap. If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good. Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too. Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply. Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards. It requires real cash investment. But it IS better. And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different. We’re talking about your life, here. Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way. Most people in the richest nation on earth perceive they can’t afford it, but really can. I blame this perception on the invention of the 10-dollar co-pay. This idea was such poison in American medicine. It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food. They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels. But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments. But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health. I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous. On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests. High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up. NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making: that is, if X symptom, then Y action with little analysis involved. recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment. When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately. Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer: I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians. Most I’ve met are smarter than me. But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000). This differential limits mid-levels to algorithmic, rather than analytical, decision-making. When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels. The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.