Irish Medical News


A tale of two doctors


Immersion in American mass media is part of the attraction of any visit to the US. A recent trip allowed a detailed perusal of two issues of The New York Times, a particularly good read, and especially on hols, with adequate time to read them from cover to cover. In the same fortnight, two doctors were profiled, operating on widely different ends of the economic spectrum. Ironically, both were passionate about personal care, i.e. providing lifelong individualised care, knowing their patients really well, and being highly available. The similarities ended there. Dr Ronald Stroka (NYT 22.4.11, B6) is a greying, singlehanded male family practitioner in Maryland.

From the description of his work, I would consider him to be a GP. He worked out of his own office, worked in a particular community, and had done so for several decades. He appeared tall, lean, dressed conservatively, and radiated the energy of the obsessive compulsive on a mission. It was a considered and detailed article, providing good background on the reality of delivering a service such as this, taking the good doctors observations verbatim, and also with contributions from many of his adoring patients. Case histories presented included several which focused on his efficacy in keeping his patients out of expensive hospital emergency rooms, as a result of decisions based on good clinical acumen, and a detailed knowledge of his patients.

The article was backed up with decent editorial values and background research. It included the important detail that in 1970, just over 60 per cent of male physicians in the US reported themselves to be self-employed and running their own practice, which had reduced to just over 30 per cent by 2007, the latest date for which this data was available. For female physicians, the figures were 30 and 20 per cent respectively. There was also an evident shift from single-handed physicians to physicians working in groups of three or more. The article included a few selected case histories from his practice, one of which pointedly illustrated the ability of the good doctor in keeping his patient out of the (expensive) hospital. The charming term applied to him by one individual was “a modern-day Marcus Welby”. The article concludes that his kind is becoming extinct. It recognises that as he, and his kind, “are being replaced by rotating medical teams, a relationship is lost.”

On the other hand…

A fortnight later we have a different physician profiled, Dr Stephen Glazer from Norwalk, Connecticut. His background was that of a hospital-based internist. Five years previously, he wrote to his own 1,000 patients, advising them all that he would no longer be able to care for them, as he was going to focus on his dozen or so wealthy patients, who were able to pay his annual fee. He was entering the medical niche market of concierge medicine.

This article went on to describe several companies delivering care to the very wealthy, including Guardian 24/7, World Care, and Pinnacle Care Health Advisory, who, along with their concierge doctors provide varying levels of technical support, including a hi-tech triage or ready room on your yacht or villa, so that you can be evaluated at any time using hardware connected high speed internet access. Top of the range here clocks it at $700,000 installation costs. Fees charged to the (wealthy) punters start typically at $1,500 (bottom of the range), to a more typical $20-30,000, but up to $75,000. MDVIP, another outfit, has 450 concierge doctors operating in 34 states, with each doctor limited to 600 patients, typically charging about $1,700 per year.

Arguably costs at the low and middle end of the spectrum are well within the pockets of middle income retirees. Appointments start on time and go on as long as necessary. Most plans include a comprehensive preventive element and a personalised wellness plan. Beyond these, the impression one has is that these concierge doctors operate in conjunction with regular insurance plans. Thus the typical patient will consult with their concierge doctor, who will guide and direct them in their journey through the regular healthcare system, screening out irregular advice and practices, assisting them towards ‘the best specialists’ and more expeditiously.

The example cited in this contest was where a patient was steered away from having a bypass where a stent was the better option, saving the patient from longer riskier care, and saving their HMO thousands of dollars in costs. The patient may well claim procedures through their regular HMO plan, but be guided through the system by their concierge doctor. The emphasis is on a detailed approach to individual care, based on high quality records which follow the patient, and where individual care is subjected to best evidence-based practice. The American Medical Association appears mildly stressed by the ethical dilemma all of this poses.

It refers to the activities of concierge doctors as having retainer practices, and elegantly and conveniently regards them as “part of the pluralism in the delivery of healthcare”. So there you have it, a tale of two kinds of doctor. I wouldn’t give up the day job just yet, but then again, it might be whipped out from under you! What price cost-effective personal care anyone ?


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