‘Concierge’ Medicine – A De Facto Manifesto

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…

William Osler (1849 - 1919), Professor of Clin...
I have a idea...how 'bout I actually know who you are, AND care about your medical issues?


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.

The AMA – Trust At Your Own Risk

Adapted from an Op-Ed in today’s NYTimes by Nicolas Kristof

Some fun facts about the AMA (American Medical Association):

  • supported segregation
  • opposed President Harry Truman’s plans for national health insurance
  • backed tobacco
  • denounced Medicare
  • opposed President Bill Clinton’s health reform plan
  • probably represent less than 25% of practicing physicians, most of which are specialists who dearly want to protect incomes from $250,000/year to over a million per year

Here is their current position on a National Insurance system:

“The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

They might have been right about opposing Clinton’s freakish health care plan.  They should have shaped the medicare debate instead of obtusely opposing it, and you can be the judge on the whole segregation and tobacco thing.

I think for-profit medical insurance is morally wrong.  Insurers should not make more money than patients, and not doctors, either.  If you want to be available to help someone in a time of weakness and need…you shouldn’t make 20% returns on them until that time arises.

*Disclaimer:  The AMA is a putrid organization from the inside out (and hopefully will be obsolete in 10 years)…but they do have it right on tort reform.

The AMA – Thinking Inside the Box

Here’s a potential Op-Ed I put together – we’re hashing it out over at the Student Doctor Network (www.studentdoctor.net) right now:


With a jolt of excitement yesterday, I clicked on an internet link that read, “AMA Responds to Medical Students’ Search for School Debt Relief”. I found the link while reading through one of the ongoing discussions about health care in the widely-read Student Doctor Network on-line discussion forums (www.studentdoctor.net).

The conversation revolves around the fact that medical students are increasingly rejecting primary care in pursuit of higher-paying specialist training after school, largely because of their debt (on average today, $180,000). To my great dismay, my elder medical colleagues recently attending their annual meeting in Chicago, failed to address the real problem at all, which is the pay-structure in American medicine.  The AMA chose to ignore this issue completely and instead tried to come up with ways to make med school cheaper. They provided some of the most out-moded and vacuous attempts at solving the problem I could have imagined. Their proposals are so devoid of reason and intelligence, I wondered if a more Machiavellian strategy drove their collective thinking.

Here are some of their “ideas”:

* Identify and promote work-study opportunities for students – This idea is, frankly, just stupid. The demands of medical school regularly destroy families and personal health. The hours are often grueling and by the 3rd year are frequently irregular. Besides, the money would be a pittance against a 40k/year bill anyway.

* Match parental savings contributions to medical education costs with financial investment funds – This doesn’t lower the cost at all, it just fleeces the parents. It’s as if the AMA thought that by draining the retirements of both the students and their parents, everyone would suddenly think med school is cheaper.

* Offer paid rotating internships for certain fourth-year students – Like the work-study idea, this is nominal money. The idea looks like window dressing to extend a rather short list of ideas in the first place.

* Provide Medicare funding for undergraduate medical education – Our social security system, including Medicare, is nearly bankrupt. They’re currently trying to cut payouts to PRACTICING doctors by 10% now, and another 5% this January. The AMA thinks they can lean on this system to pay med students?

* Make medical education tuition costs and/or loans deductible – This idea MIGHT be helpful if confined to those who choose primary care.

* Consider using a competency-based curriculum that could shorten the length of undergraduate education and medical school – This is the only idea they came up with that makes some sense. There’s a LOT of inefficiency in all the hours required for medical training, especially the 4-year degree requirement prior to school. Everywhere else in the world runs a 6-year program which includes undergrad. In the rest of the world, if you want to be a doc, be a doc. Don’t study naked statues in Rome first.

* Use endowment funds to lessen the impact of educational costs on medical students – The Harvard endowment is in the tens of BILLIONS of dollars and they still regularly pump their undergrad and graduate students for tuition. They lean hard on their alumni for donations also. Money comes in to these private institutions. It rarely goes out.

Primary care medicine is generally good work, and many would-be doctors every year choose the specialty on the merits of the job alone. Students are often drawn to the field for altruistic reasons, but few are happy in a system that not only demands their altruism, but preys upon these sentiments for even further gain. Thus, if an American medical graduate wants to get out of debt, have a retirement and send the kids to school, they’re wiser to choose specialty medicine.

The AMA is trying to say that med school needs to be cheaper so people are less burdened by debt when they make their specialty choice. While containing costs and possibly shortening the training time will help, the REAL problem is pay differential between specialist and generalist. The answer to that problem is simple, too: Pay specialists less, pay generalists more. Currently, our system financially rewards procedures and specialist care while paying relative ignorance to primary and preventive care. The American medical system is the most expensive in the world, but ranks around 18th place globally when all important health markers such as maternal mortality, infant mortality, obesity, diabetes and life expectancy are averaged together. The countries that beat us – Cuba trounces us at a fraction of the cost, for example – do so largely because they invest intelligently in primary care medicine.

It could be that the AMA is craven and strategic; their true goal being to prop up this specialist-heavy medical system that is overly reliant on high-tech, high-cost procedures. They may believe that primary care doctors should be replaced by lesser-trained physician’s assistants, “doctor” nurses, and nurse practitioners, all of whom have a lower threshold to refer to specialists. But specialist care is expensive, and the money is drying up. When the money’s gone, the specialists will be out of work too. So, if they aren’t being underhanded, then this particular effort at solving the problem is merely inept. Either way, they’re shooting themselves in their collective feet…a top-heavy medical system cannot sustain itself.

It is time for Americans to accept the fact that most of the developed world has better medical systems and healthier people than we do, at significantly less cost. We can catch up to them by simply investing in preventative and primary care medicine. But if even the AMA can’t (or won’t) address this issue, who will?