AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2003, Volume 5, Number 11.

Clinical Cases

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"Concierge" Practice and the Profession's Contract with Society

Physicians who change their practices to concierge medicine may lose valuable patient-physician relationships.

Commentary by Troyen Brennan, MD, JD, MPH

Dr. Leanne Todd, a primary care physician in a small town, has become tired of constantly apologizing to her patients for the hours they spend in her waiting room, her overbooked appointment book, and the constant rush of having to move on to the next patient. The 15-minute time slots Dr. Todd's scheduler allots do not permit her to have a personal conversation with each patient or allow them to air all of their health concerns.

After some serious thinking and conversations with a colleague and an old friend of hers in Florida, Dr. Todd has decided that she will transform her current practice into a concierge medicine business. She has worked out the finances and realized that she doesn't have take a pay cut if she has fewer patients and charges them more, and it will be more satisfying for the patients, more fulfilling for her, and less stressful for her staff.

Dr. Todd has sent each of her current patients a letter explaining that she will be changing her practice and that they will be charged a flat annual fee of about $3000 to continue to see her. The letter explains that under the new practice set-up Dr. Todd will have fewer patients and will offer same-day appointments with more time to talk to the doctor. Dr. Todd will also start making house calls and carry a cellphone so her patients can reach her 24 hours a day. She tells her patients that she will continue to keep appointments as scheduled for the next 6 months but will not schedule any new nonurgent visits for patients who do not wish to participate in the new practice. Each letter contains a list of other physicians in nearby towns complete with the type of insurance each physician accepts for patients who do not wish To join Dr. Todd's concierge plan and decide to change doctors.

Since the letter was sent out, Dr. Todd's office has been flooded with phone calls from her patients. Some of her patients are willing to pay the extra fee and are thrilled with the opportunity to receive more personal attention. Although Dr. Todd's staff is overwhelmed with all the phone calls, they are looking forward to the practice transition and the chance to work with fewer patients. Mrs. Liles, a 73-year-old patient, has called 4 times since she received her letter. She insists to the staff that an exception be made for her and that Dr. Todd continue to see her.

Mrs. Liles lives down the street from Dr. Todd's office and does not drive. The closest primary care physician is a 30-minute drive away. Mrs. Liles keeps telling the staff that they must inform Dr. Todd that she doesn't drive and that she should be allowed to continue to see Dr. Todd without paying the extra fee.

Commentary 1

by Troyen Brennan, MD, JD, MPH

The evening I received the invitation to read and comment on this case study, I was late to rounds on a patient who had just undergone cardiac catheterization. She is a 63-year-old woman, somewhat disabled by diabetes and high blood pressure, who is insured by the Medicaid program. She had had some angina-type symptoms and failed a stress test, leading to the catheterization study. The angiograms showed only single vessel disease that was not amenable to stenting, and the cardiology team recommended medical management.

When I entered the room, she was surrounded by 2 friends, a case manager, and her nurse. It was 7PM, but she was getting ready for discharge since the hospital was very crowded and her catheterization had gone smoothly. When she saw me, she nearly shouted, "Dr. Brennan, I am so mad at you! Where have you been?" It was true I had not been in to see her the night before (she was a rare admit-the-night-before case because of her often brittle diabetes), and she had found herself beset by fellows and attending physicians from the cardiology service who had "told me about a million things that could go wrong and confused me terribly!" She said all of this with a big smile on her face, especially when I assured her that the doctors had been in touch with me throughout the stay, and that we were all pleased with her progress. We had a very nice visit and developed a clear game plan for the next few days so that we could keep an eye on her renal function and diabetic control postcatheterization. Her trust in me was very gratifying, but I did feel bad about not guiding the process the night before. I had let her down.

We are old friends, in the special, formal kind of way that a doctor becomes friends with old patients. We talk when she sees me in clinic about a variety of her personal matters, and she likes to hear about my family and life. I very much enjoy her company, knowing that it is not a relationship of friends, but a professional one. She depends on me to ensure her health stays passably good, and I have responsibilities to her that neither she nor I expect her to reciprocate. I have known her for a long time, and know her diseases pretty well, and we have been successful in keeping her relatively healthy. She interrupts my personal life with calls when things are going poorly, and on more than one occasion I have had to depart from social events or family time to see her in the hospital. All this is no big deal, it is the way that most primary care doctors take care of their patients.

Now how could I possibly tell her, "Guess what, you now have to pay me $3000 per year to take care of you"? She could not afford it and would have to find a new doctor and in many ways start over in building relationship. I would lose a friend, but moreover, I think I would corrode in my own mind the sense of a special relationship with my patients. I do get paid for caring for them, but I care for them because I enjoy being a doctor. Telling this patient and others like her that I cannot continue my relationship with them when I enter a concierge practice would change all of that. And my patient, I can imagine, just barely, how perplexed and hurt she would be.

Forget about all the policy and ethics and economics arguments that can be made against concierge medicine, and just focus on this: what is the meaning of a patient-physician relationship if it can be terminated abruptly and for such coarse reasons? I hope that reflecting on that point will lead most physicians to reject the concept so that boutique practice will not become prevalent. If that is not the case, and we physicians cannot support all patients in the way our professional values guide us, then we risk losing our special voice in matters surrounding the organization of health care.

Troy Brennan, MD, JD, MPH, is a professor of medicine at Harvard Medical School and president of the Brigham and Women's Physician Organization.

Note: The American Medical Association recently issued policy on the topic of concierge medicine finding that this practice is not inconsistent with a pluralistic means of health care delivery but has identified ethical concerns that warrant careful attention. See what the AMA Code of Medical Ethics says about this topic in Opinion 8.055 Retainer Practices. American Medical Association. Code of Medical Ethics 2008-2009 Edition. Chicago, IL: American Medical Association; 2008:225-227.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.