Op-Ed: Concierge Medicine
The health care we should all have
When people ask me what I do for a living, I used to sheepishly mutter “I’m a concierge doctor,” as I was keenly aware and sensitive to the public perception of concierge medicine (see: celebrity overdose). Now, after several years in the field, my tune has become boastful and bold: concierge medicine is the ideal practice of medicine and should be the standard of care.
Incredulous? Let me prove my point.
Today I followed up with a patient with recurrent vertigo that has impaired his quality of life. When we first met, he had already seen several specialists at respected academic institutions over the last four years, yet his symptoms were unchanged. In a typical practice, where a primary care physician has thousands of patients and only 20 minutes, this would be one problem of many that we gloss over as we take notes and watch the clock. In that practice, I would either refer him to yet another specialist or, more likely, ask him to follow up with someone he is already seeing. But this isn’t a typical practice.
I spent two hours reviewing his records, then another two hours discussing his symptoms with him for myself, and finally I spent the entire afternoon researching papers and treatments for his vertigo. We then followed up a few days later and I again worked through a second iteration of interview, thinking, researching, and planning. After four days I suggested two medications that have excellent evidence but for some reason had not yet been suggested to him. In addition, I suggested a very specific low risk procedure with great evidence that was also never discussed. We check in every week as we titrate these medications and his results are promising. We are both excited and hopeful.
A question I have been asked many times is “why didn’t anyone else suggest this?” And the answer is simple: time.
Primary care in the United States often involves a patient panel of thousands with short, 15-20 minute visits that need to cover a myriad of patient concerns. During this time, one must interview the patient, examine the patient, review pertinent labs and imaging, then formulate a plan in accordance with best practices. Rinse and repeat this process until 5pm, after which you need to write your clinic notes and respond to patient messages and phone calls. This is a recipe for burnout and disaster.
We already know that as doctors fatigue, clinical medicine is impaired. Although this is a logical conclusion, we actually have studies that confirm physicians are less likely to order appropriate cancer screening tests as the day progresses (1) and that procedures are less likely to identify abnormalities later in the day (2). There is no time to critically think and research on behalf of the patient. We are forced to diagnose and treat based on our initial impressions of the clinical scenario, which are not always correct. The vast majority of healthcare suffers from Type 1 Processing, which is mired in biases and heuristics, when in fact all patients would greatly benefit from physicians utilizing Type 2 Processing. While type 1 processing is pattern recognition and intuition, type 2 processing involves slower analytic thinking. The key difference between these modalities is, of course, time.
The standard of care should clearly involve fewer patients for the physician and more resources to coordinate care. It takes time to truly care for an individual and time to foster a meaningful relationship. It takes time to think, diagnose, and treat. Most importantly, it takes time to care and time to recover our own energy to continue caring. Unfortunately, our current healthcare system falls incredibly short in this respect. Concierge medicine offers not only excellent patient care, but it also offers better physician care, and one cannot exist without the other.
Hsiang EY, Mehta SJ, Small DS, et al. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Netw Open. 2019;2(5):e193403. doi:10.1001/jamanetworkopen.2019.3403
Sanaka MR, Deepinder F, Thota PN, Lopez R, Burke CA. Adenomas are detected more often in morning than in afternoon colonoscopy. Am J Gastroenterol. 2009 Jul;104(7):1659-64; quiz 1665. doi: 10.1038/ajg.2009.249. Epub 2009 Jun 2. PMID: 19491841.