We’re having a great debate on the subject of retainer/concierge/whatever medicine, starting with piece by Dr. Centor , an internist I high respect. I fired back this piece and now Dr. Centor has responded . I must give Josh at KevinMD some credit for getting the debate started (but please Josh, post about something else now and then!).

We’ll go through Dr. Centor’s response piece by piece, ’cause I find it’s the best way to address points and give my own thoughts.

Graham is an idealistic 5th year med student (he spent a year doing research.)

Guilty, yes, as charged. I actually describe myself as an “idealist realist” (or “realistic idealist,” take your pick) in that I believe we can always strive to do better and improve: that we should always aim for and want the best. But I grudgingly accept and recognize that reality don’t always jive with that aim. Moving right along.

Upon further reflection, one must evaluate the current status of outpatient internal medicine (because currently the great majority of retainer practices are internal medicine.) Physicians are fleeing from outpatient internal medicine. Our current reimbursement model causes physicians to run on a treadmill, destroys their work life balance, and leads to a constant sense that they are delivering substandard care.

Look at our residents. Very few choose outpatient medicine these days. They either choose subspecialties or hospitalist jobs.

Look at practicing outpatient internists. They are leaving practice at a steady rate. Some switch to hospital medicine. Some go back to do fellowships. Some leave medicine entirely.

I totally agree with you, Dr. Centor. We joke that all the medicine residents at Stanford are going into either Cardiology or GI, because it sure seems that way.

Dr. Centor goes on to talk about the financial disincentives to work in primary care: the poor reimbursement due to third-party payers, the inability to spend the time truly needed with a diabetic, etc. Again, we’re in fully agreement here. I really like this bit:

Most outpatient physicians practice medicine in a way that insidiously harms their self esteem. They know that they are not providing the best care. They know that they cannot provide their patients with the support that they really need.

I believe that most retainer physicians see their practice style as the only tenable solution. I suspect that many of them would have left practice for another job if they did not have this option.

If retainer physicians are unethical, then what about physicians who quit seeing patients entirely and enter medical administration. What about any variety of subspecialists?

And this is where I think Dr. Centor and I are missing each other. My concerns are those from more of a public healthy, health policy lens, whereas Dr. Centor is viewing the situation from an equally valid perspective–that of the primary care doc on the front lines. He makes a great point: if the decision for the primary care physician is between retainer medicine and giving up medicine, that makes the choice seem more reasonable to me. And I have no doubt that many primary care docs believe they simply aren’t able to deliver high-quality care to their patient census. And speaking of ethics, I’m certainly in the guilty field here, as I’m not going into primary care (although I’ll be doing my share of ‘primary care’ in the Emergency Department and seeing uninsured patients, something I love about the field).

Dr. Centor then goes on to talk about how if retainer medicine succeeds, perhaps it will encourage more residents to go into primary care, which would achieve the goals of more primary care physicians in the US.

But hold on here, let’s give my perspective a look with some back of the envelope math. According to the 2006 Bureau of Labor Statistics data , we have
109,400 Family and General Practitioners in the US, and 48,700 General Internists in the US. That’s 158,100 primary care doctors in the US. With about 28% of the US being under 20, that leaves 236,000,000 adults that need a primary care physician. That’s almost 1,500 people per physician.

Say we even took all the physicians in the US–415,630–and told every single one they have to practice primary care. We divide it up again, and it’s still 567 patients per physician.

Let’s be practical here, people–retainer medicine will not work as a model to fix primary care. It will certainly make primary care physicians’ lives better and their wallets thicker (which I’m not opposed to), but it simply won’t fix the problem.

Dr. Centor, the ball’s back in your court.

PS: “Single payer systems do not provide social justice.” Huh? They are certainly far from perfect, but certainly do a better job of providing limited resources equally to all citizens than, say, our system.

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