‘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…

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.

I KNOW What This Is

No, you don’t.

In medicine, certainty is a very dangerous thing.  It’s ok to be certain about things like the price of gas or your dislike of prunes (couldn’t blame you).

Certainty in medicine is quite another.

And, although politically incorrect to say it, I’m finding a frustrating amount of unjustified certainty among the ranks of the “mini-docs”.  By mini-doctors, I mean all the permutations of lesser-trained white coat-donners.  The PA’s, ARNP’s, Dr. RN’s, LPN’s, etc.

Hello. I'm not-quite-a-doc. I know EXACTLY what you have.

Exposed to about 1/3 of the training of the average primary care M.D. (if that), these sorta-doctors function in American medicine with nearly complete autonomy (and are constantly pushing for more).

I have no problem with these relatively new additions to the medical field.  I myself criticized my training as too long, redundant and costly while enduring it.

But the more I work with patients who see them, the more I run into decision-making that is flat-out problematic.

I should mention that many P.A.’s I’ve trained with were clearly smarter than me.  A couple of the ARNP’s I currently work with are easily as  bright or brighter than my – shall we say – earth-friendly mental wattage.

But I’ve learned that smart brains often don’t  lead to good medicine.  In my opinion, what makes the best medical decision-maker is an acute awareness of ignorance.

You could call it intellectual humility, if you wish.  It could be that all the hours of training in medicine really just cultivates this humility to refinement.  I can see the value of that.

In the last week, I have dealt with numerous decisions of certainty in medicine that were completely unjustified.  All were made by PA’s and ARNP’s.  As patients described their experiences, I could tell their previous providers were of the para-doc variety even before they confirmed it for me.

“I’m here for antibiotics, Dr. Secretwave101.”

“Really?  What for?”

“I have pneumonia again.  I had it 5 times last year.  I just have to come in and get antibiotics for it.  It’s such a pain!”

“PNEUMONIA?  FIVE times in a year?  Are you sure?  Confirmed by chest X-ray?  Do you know the organism?  Bacterial each time?  Which lung?  Was it a particular lobe?  Were you hospitalized?  Did you have pulmonary scarring as a child?”

“Uhhh.  I don’t know any of that stuff.  I just need the medicine.  I always just come in with this cough and get the medicine.”

Pneumonia is a big freaking deal.  Real pneumonia kills people.  Like, healthy, not-old, not-sick people.  Real pneumonia almost never hits someone 5 times in a year.  Once, and you’ve had a tough previous 12 months.  You get it 5 times and you’re basically telling me that you’ve spent the previous year in a hospital with chest tubes, IV meals and a bag to catch your pee.

There were two problems with the patient encounter.  One, the patient wasn’t well educated by her provider, who clearly had numerous opportunities to clarify things for her over the previous year.  She didn’t have pneumonia 5 times, she had a cough.

The provider also never worked up the cough to see what it actually was.  No X-rays.  No sputum cultures.  No pulmonary function tests.  Just antibiotics.  Broad-spectrum antibiotics.

In another post, I will describe why throwing antibiotics toward a cough with no evidence of bacterial involvement is absolutely catastrophic for the long-term survival of the human species.  That statement is a rare instance on this blog where I’m not stating hyperbole, either.

Antibiotic resistance is real, and the results of it will kill you.

I also recently recommended that my sister-in-law take her son into an urgent care center to be evaluated for what sounded like strep throat.  That would be, Streptococcus Group A pharyngitis.

“Did you know,”  I asked her, “why we treat strep throat?”

“Well, he could get really sick, right?”

“Yes, but not from the throat infection.”

“So, we’re not treating the throat?”

“No.  That goes away.  Most pharyngitis is viral and goes away.  Even bacterial goes away.  We only need to treat one specific cause of pharyngitis, Group A Strep, because it can also cause heart disease, kidney disease and all kinds of other stuff.”

“I didn’t know that.”  She replied.

I didn’t either.  Not until years into my training.

The next day, I found that my nephew was taken to a P.A. at the local Urgent Care and without a culture or any other objective work up, he is diagnosed with “strep throat” and given antibiotics.

“I don’t even need to test this, the symptoms are so classic.”  The “doctor” reportedly said.

Two days later, the boy’s little sister gets sick.  There’s no culture from the back of brother’s throat.  We have no idea if what he had was viral, bacterial, fungal or nothing at all.  He may not have even needed the antibiotics, and likely didn’t have the right ones if he did need them.

Now we have no idea what his sister has.  Is it the same thing?  Is it something new?  I guess we’ll just throw some antibiotic at her, too and say they both had STREP THROAT, even though we have no evidence of this.

Did my nephew's throat look like THIS? Did anyone even look?

Certainty in medicine flat-out leads to bad medical care.  Everybody has the urge to think they’ve got this or that totally nailed from time to time.  Doctors too.  Maybe doctors more than other health professionals.

But my experience so far is that certainty increases with less training.

My warning to you is this:  If your health care provider is CERTAIN about your health problems, you don’t have a very good doctor.  Humility comes from a wide differential diagnosis.

In nature, the humble survive; the proud die.

Another Study

A group called The Physicians’ Foundation came out with yet more evidence (check it out here) supporting what you probably hear from most of the MedBlog community in different forms all the time.  If you read my blog regularly, you’re probably also aware of some of my cyber-colleagues like Kevin M.D., Dr. Wes, The Happy Hospitalist, Fat Doctor, Shadowfax and others espousing similar concerns.

We’ve all talked about how primary care is becoming untenable.  Now there’s a questionnaire survey that was mailed to every primary care doctor in the country, and it backs up our claims too, essentially asserting:

Primary care medicine sucks if you can’t spend time with your patients.

We didn’t go into medicine (and enormous debt) to do paperwork and argue with insurance companies.  People who do paperwork and filing for a living don’t understand our intolerance for their way of life, but it’s a fact that not everyone likes the sterile confines of alphabetization, algorithms and cubicles.

Some argue that the answer is more allied-health providers for primary care, like N.P.’s, Dr. Nurses (weird one, I know), P.A.’s, etc.  I disagree.  Excellent health systems provide excellent health care, and that starts with well-trained providers with doctorate-level education.

Residency-trained family medicine doctors average 12 THOUSAND hours of training before practice.  Nurse Practitioners average around 3500 hours.  Same for P.A.’s.  These people are easily as intellectually-equipped as doctors, but I think the idea that they are as well trained or can replace physicians is ludicrous.

I also hope lawmakers intent on saving our system don’t rush to the EMR (electronic medical record) as the messiah of American medicine.  It isn’t.  I use one every day, and it does very little to improve care and absolutely nothing to improve efficiency.  If EVERY doctor used an EMR that talked to all other EMR’s, efficiency might improve somewhat.  But our capitalist system has provided us with dozens of competing companies and, given our obsession with medical privacy, none of these programs communicate with each other.  Digital charting takes hours and is only slightly improved by hacking away on the keyboard during the entire patient encounter, detailing everything as it happens.

And, for a future blog, those records do nothing to protect doctors from litigation.  Trust me.  Nothing.  If anything, they help the plaintiff.

Also on the EMR topic, it is colossally more expensive to sustain than just some basic paper and dictated notes.  Companies LOVE the idea of EMR’s because the required tech support, and database maintenance, and program upgrade requirements are virtual gold mines.  In the end though, it’s another of thousands of examples of business and enterprise making money on medicine – the real reason American medicine is falling apart.

Like the canary in the coal mine, as Family Medicine goes, so goes American health care.  If well-trained doctors are getting out of the business, the natural corollary is that you, over time, will be getting sicker (and poorer).

Kennedy Pulls Through

Pay cuts to doctors who take medicare (this would be virtually all of us) have been blocked by Congress today after a dramatic vote led by Senator Edward Kennedy.  It was a heady day in the world of medical politics.

A few years ago, the government decided it would be a good idea to ‘balance the budget’.  A balanced budget is nothing more than making sure you spend at least a teensy bit less than you make.  My readers of conservative mind will probably find this balancing act a rather good idea.  This includes me.  Always good to not spend money you don’t have.

The problem is that under the guise of ‘balancing the budget’, politicians decided to cut doctors’ pay.  This decision does nothing to help fiscal matters, but is very politically-expedient.  Insurance companies have a tremendously powerful lobbing organization, and most officials figured it was smarter to knee-cap docs than insurance billionaires.  Thus, they voted to continue directing the jet-wind of dollars toward an industry that exists by preying on sick people.

Recently the first of two MAJOR pay cuts finally arrived, set to begin on July 1st.  The AMA – an organization I generally regard as a lifeboat filled with “The Others” from Lost (they’ll probably kill you…but they just might save you if they feel like it) – actually focused themselves and put up a good fight.  They lobbied hard, went public and pressured wavering lawmakers.  Eventually, the Democrats (Max Baccus kinda got the ball rolling) put up a proposal to block the cuts, and after some wrangling, a law passed in the House by a landslide vote 355 to 59 vote.  Good.  Now all that was needed was the Senate to pass the same law.  Then doctors across America could go back to wondering how they’re going to pay for the rising costs of insurance with Medicare payments that haven’t kept up with inflation since the ’90′s.

The problem is that the Senate is where the insurance lobby has more traction.  It put more lobbying effort there in the first place.  Furthermore, they have George Dub in their pockets as well.  He’s so strung to them he has vowed to flat-out veto a bill that blocks the pay cuts.

“WHY?”  You might ask.  “WHY would he do that?  Oh, that’s RIGHT!  Dubbage is a conservative.  He’s hewing to good, conservative economics.  It must be that the one expense we can’t pay for while keeping a balanced budget is doctor’s salaries. “

Not even close.  Bush is more liberal than Clinton when he was a barefoot hippie not inhaling Russian weed and perpetually copulating in the back of astro-turfed pick-ups.  Bush has no principles.  He did once, but he’s been bought.  By insurance companies, among others.  He threatened to veto the new law for the simple reason that it pays for itself by lowering payments to something called “Medicare Advantage”.

Medicare Advantage is medical insurance from a commercial insurance company, but instead of the patient paying the company – like normal – the government pays for it instead.  Medicare pays for medical care for 44 million elderly and disabled Americans.  For 80% of these people, Medicare simply sends money to doctors when the doctor sends Medicare a bill after seeing a patient.  The other 20% (approximately 8.7 million people) use MA (Medicare Advantage). Enrollment varies widely across states.  Over half of the enrollees are located in CA, FL, NY, OH, PA and TEXAS.  Most of the rest are in a smattering of states and some states have almost nobody on the plan.  The plan is ostensibly accessible to everyone, but in fact is unevenly utilized and by definition costs the system more because TWO payers are in the mix rather than just one.

Bush wants to protect this system by lowering doctors’ salaries.

Medicare doesn’t pay great (if the doc bills $100, they’ll just sorta figure they’ll send about $75…somewhere in the world, that’s called stealing, but not here), but they do pay.  Until we come up with a more comprehensive system, Medicare is worth keeping around.

The Senate was initially dead-locked on the bill.  Democrats were united in favor of it, but a number of conservatives were against it (the ‘big business’ thing, you see).  Today, however, just at the Senate began to re-vote on the issue, in walked a weakened but determined Ted Kennedy – recently released from the hospital – leaning on many assisting arms.  He slowly made his way to the podium and cast his vote in favor of the bill to thunderous applause from both the gallery and the representatives – traditionally a no-no in the staid and musty Senate chambers.  Caught up in the moment, numerous Republicans switched their votes, and the bill passed by a solid margin, 69-30.  If Bush has the bald temerity to veto the bill, and everyone re-votes just as they did today, the bill would survive even the President’s craven attempt at pandering.

The answer to the woes of our medical system do no lie in harassing doctors or paying them less – a trend that has been gaining prominence over the past 20 years.  Sensible liability, insurance profit constraint and funding for primary care is what will save American Health Care.  Our government needs to figure this out quickly, because currently we’re relying on the common-sense and courage of a feeble, white-haired lawmaker dying of brain cancer.

Email

Recently I began providing my email address to my patients.  I’m not the only one, either.  You can read about how surgeons are starting to stay in touch with their patients, and how both parties are generally happier about it.  There’s a quick article about this issue here.

One of the big-time medical blogs out there, Kevin M.D., also weighs in on the subject and points out that there are some problems with this new practice.  One of the big ones he mentions is that email communications are probably often not HIPAA compliant.  If you don’t know what HIPAA is, I recommend that you NOT educate yourself.  HIPAA is classic D.C. armchair policy-making that is meant to protect patient privacy, but in reality does less for this goal than intended.  I’d prefer the acronym HIPPO.  The policies are minute and voluminous, arcane, endless, cumbersome and impossible to follow perfectly.  Worse, they’re meant to apply to every single health system in America.  No regional variation.  No State individuality.  EVERYBODY. 

In general, of course, the idea (initiated in ’96 by Bill Clinton) is a good one.  Nobody wants their health info on YouTube.  But while health information certainly is sensitive, the frank truth is that it isn’t high-value stuff.  I’d be much more worried about someone using my identity information than my medical history to ruin my life.  HIPAA policy – and the enforcement of it (they call it compliance) – has become an entire career field…all to protect information that is almost never interesting to anybody, even to the guys in ski-masks and dark glasses.

At any rate, it appears that doctors may not be able to talk to their own patients by email unless the system is hyper-encrypted to keep bad guys from getting the info and…oh, selling it on the medical info black market in Paraguay or whatever. 

You can see that I have a dim view of government policymaking.  I think government policy is often nothing more than a cathartic exercise for people with an above-average need to feel important.  Writing stuff – even stupid stuff – that other people have to obey will make you feel important.  In fact, the more stupid, the better.  You’re in control.  “DO IT!” you can demand, ”Even if you think it’s dumb.”  You’re The ALPHA.

Government wonks do this all the time, resulting in thousands of rules – which fulfills their own subconscious needs – that tend to be laughable and illogical when applied to every single human in America.  HIPAA is supposedly in place to protect patients from losing their info.  With respect to email correspondence between doc and patient, shouldn’t the actual patient themselves have the right to correspond with their doctor however they choose?  No.  You, dear ignorant patient (and doctor).  You have no idea what is good for you.  We here in Rached, D.C. will take care of you, whether you want us to or not.

The truth is that doctors, me included, HATE making phone calls.  They take forever.  The number is invariably wrong.  You have to find somewhere to talk where your conversation isn’t going to be overheard.  You NEVER get paid for them (unlike lawyers, who must have listened in their business classes).  And often the patient isn’t there and you have to fret over leaving a message or not, never knowing who is going to hear the message, etc. (violating HIPAA, again)  Ultimately, I feel bad that it takes me so long to get back to a patient when they leave me a message.  Email is a perfect solution. 

Or was…until policymakers totally remove this option from patients and their doctors. 

The number of people edging themselves between patients and their doctors over the past 30 years is truly amazing – government, lawyers, insurance agents, pharmacy, to name a few.  The evolution of this new army of medical middle-men, I believe, will be what is remembered about American medicine 100 years from now.  And I think it will be looked upon as a largely aggressive and capitalistic change that generally harmed patients, not helped them.