The Black Hole of American Medicine

I didn't invent that graphic phrase. It was created by a former and much-missed physician who left a thriving practice at the age of 49. It describes the frustrations of a dedicated and talented MD who felt he could no longer exist under the current system. Rents on office space were climbing exponentially. Insurance requirements were increasingly onerous. As the New York Times noted recently, many doctors are refusing to accept Medicare patients because of the overload of restrictions and forms, not to mention the lure of higher billings without the government interference. They refuse even when the patient offers to pay out of pocket without billing Medicare. Some doctors frankly admit that they don't want patients that require too much care because the doctors are too busy. Malpractice insurance rates keep climbing. Pharmaceutical companies are not always forthcoming about the problems with their products. And the overwhelming amount of paperwork required is daunting.

The result is a broken system, one that serves neither patient nor doctor.

One solution being tried in California is the so-called "Boutique" or "Concierge" practice. Doctors don't like the term Concierge because it sounds pejorative, although it perhaps describes rather faithfully how patients view this development. (But don't expect good theater tickets with the medical advice). Basically doctors are paid an annual fee, called a retainer, ranging I have heard from $1800 to $5000 per year. One contract I have seen says the amount includes up to fifteen office visits annually excluding the annual physical, same-day or next-day appointments, emails and faxes (Wow. How about that?), up to two visits per year to the patient's home or workplace if the doctor feels it is needed, and up to 30 hospital visits every year.

The reaction here in California has ranged from envy to dismay to fury. The Concierge Practice certainly fits into the administration's penchant for dividing the haves from the have-nots in our society. The emphasis on money sets the tone for the relationship between patient and physician from the start. And those who don't want to cough up in advance can just keep on coughing.

Which brings up another issue, one that is too often overlooked in medical schools. Many medical personnel define their patients by their diseases. I once had a lab technician say of me "here comes Gaucher" (a bit of genetic mischief that unfortunately inhabits the same body I do). Most of us, on the other hand, do not define ourselves that way. In fact one of the important elements of wellness is to define yourself by who you are, not by what illness has attached itself to you. Many doctors relate better to their tests and machines than they do to their patients. A physician recently told his nurse to give me an EKG before I had even met him. Another spoke for five minutes - to the wall. They seem to think that the only truth is the truth that you can measure. But truth is multidimensional and stretches far beyond what they learned in their textbooks.

If past years are any indication, the trends that start in California tend to spread nationwide. Are you prepared for Boutique medicine in your town? Email your comments to me at and I will post them in future issues.

c.Corinne Whitaker 2006