From the webpage of a concierge (boutique) medical practice
"What do I do when I need a specialist? To ensure continuity of care, we will help coordinate all specialist referrals. We feel communication between primary care physicians and sub-specialists is crucial to your health. (Available at Platinum Membership Level only.)"
Huh. I thought one's primary physician, GP or internist, or for a lot of women, gynecologist, always coordinated specialist referrals. And they say it's crucial, but in the next clause say it's only for the most expensive sort of membership.
If it's crucial, shouldn't everyone have it, and I thought it was standard anyhow.
FTR I'm not considering joining this or any similar thing, but a friend has a concierge doctor, and things didn't go well this month so I'm trying to learn more about it. For reference only:
AFAIK, it is not standard for individual doctors to talk to each others, especially if more than one other is involved. Your regular internist may talk to your cardiologist, but the cardiologist is not talking to your podiatrist.
We use a very good regional HMO and all the doctors have all your information on the computer. No additional charge. I guess is you want a doctors to treat you special, you have to pay. Sounds like a way to make money from snobby people.
It sounded to me like that's all they were promising.
And that they weren't promising this anyhow. For one thing, it says "between", not "among".
My friend is far from snobby, though I think his father made a lot of money when he was growing up, and his standard of living has gone gradually downhill, because of business reverses and divorce. But he had a concierge doctor. After he injured his shoulder cuff a month ago helping a stranger push his car out of the snow, he was sent to physical therapy where it appeared he was injured further. He couldn't sleep, didn't want to eat. He and his doctor texted back and forth, but the doctor never suggested he come in, only to visit a chiropractor and "pain management". He was even taken to the emergency room a week ago, but all they did was pain investigation, that is, x-ray his neck and say it was fine. When the friend who drove him said, "Look at him!" because he looked terrible, they said he should see his doctor.
Finally, a friend who's a doctor came over and noticedthat his fingernails were blue and his ankles swollen (didn't rebound when pressed with a finger), and said he had to go to the hospital 4 days ago. I was told the hospital doctor said he only had one day to live. Yesterday he had heart surgery to "scrape the infection off of his heart valve" (iiuc), and replace a valve or two, and he's doing well. I know he's stubborn and that's part of the problem, but where was his hot shot medical care when he needed it? He's 79 years old, but not overweight, doesn't smoke, works more than 40 hours a week (some of it painting, moving a 20 foot ladder around), walks 6 miles on days he walks, only started to slow down two years ago but is still stronger than I am, at least he was before this started.
His friend, in a different specialty, said he may have had this problem for 6 months and that the injury at the physical therapy may not have happened at all, and may just have been a symptom of the heart problem. But his doctor didn't look at him.
My medical training, med school, internship and residency (1967 - 1975) emphasized the importance of direct physician to physician communication regardless of whether it was a shift change hand off, vacation hand off, or referral. My colleagues and I were taught that it was an issue of ethics because it directly affected patient quality of care and safety. Those were the days when almost all physicians not in academic practice were in private practice. Those days are long gone and now the green eye shades in the practice management front office dictate how many patients/day must be seen and monitor logs for the presence of charges filed for all services rendered. Most younger and mid-career practitioners regard those now obsolete attitudes about what is appropriate standard of care with as much amazement as they do the fact that we actually were able to enjoy life without an internet. I applaud your sense of what's an appropriate standard of care, but I'm sad to say you're in a dying minority.
While the green eye shades and "bow ties" have their place in this problem, let's not forget the all knowing, all seeing, all incompetent government who knows better than any doctor or patient what the patient needs.
HIPAA and ACA have done more - IMO - to cripple medicine and reduce the level of care in this country, than anything else. When I go to the doctor I want HIM/HER to treat me, not the practice manager, the insurance company or the government.
Well, yeah. Above they say it's crucial, at least for Platinum members!
This is very sad to hear.
Maybe this relates to the fact that primary doctors and specialists don't seem to mind when a patient calls a specialist directly. In the old days, wasn't it rude to the primary doctor to go "over his head" and try to make one's own appt. with a specialist? And didn't specialists refuse to accept patients without referrals?
I notice that the TV commercials for AARP Medicare supplemental ins. say that a referral is very rarely required. That means someone can call the specialist directly, iiuc? (I have that insurance but hadn't seen that commercial when I bought it. I don't remember if I noticed it in the web description.)
The insurance will pay, but some doctors still want you to get a referral. Perhaps one reason it to be sure you really need to see that specialist. If you do self diagnosis and make an appointment with a heart doctor but you really need a lung doctor you just waste time and money.
I agree with doctors and nurses talking with each other, it sure allows for more consistent care. Would not want each MD and RN to freelance, and write and change meds and treatment plans. Thank you for your good quality work, Doctor.
But, I recently went through my family doctor going into MD VIP practice which would have cost each of us $1,600/year and was not a deductible insurance expense.
I was seeing him twice a year and wife on occasion so we quit him.
Only patient I know that stayed with him is a Parkinson's patient that needs coordination he might provide.
For both your questions, more so in rural practices than in urban ones, but mostly you're right. Of course, those were also the days when only a minority of physicians considered their patients as important participants in the success of the prescribed plan of care. Many were insulted by patients who questioned their recommendations and especially by requests for a second opinion. One of the few good things to be said for today's health care delivery environment is that many more physicians today understand the importance of informing patients about their condition and making patients more active, participative partners in their care (at least the better physicians do so).
One of the biggest problems with health care delivery these days is the lack of coordination among all the professionals who may be involved with a particular case. No one has the big picture and no one is able to communicate the complete picture to the patient and/or family. This situation has been aggravated by insurance companies and changed community practice standards that no longer require a patient's primary care physician to refer their patients for specialty care. Each professional participating in the case acts in isolation unless they take the initiative (and time, and today more than in the past, time is money) to determine who else is doing what and proactively communicating with the patient's "regular" doc, or if there was none, at least with the admitting physician in the case of hospitalized patients. The worst problems occur with the patients that most need coordinated care, i.e., the sickest, most complicated, hospitalized patients. Of course, the policy of directed referrals is not without shortcomings. I could write an essay on the politics of referrals and of how either patients or colleagues are supposed to objectively know which practitioners are truly competent.
Anyone who either trashes the existing health care delivery system by targeting one or two specific components, or says they have a simple panacea for all that is wrong with the system is at best naive, possibly just ignorant, and at worst, speaking from a badly biased politicized high horse. As with essentially all complex systems, the problems are complex, as are the potential remedies.
I can give you a clear example of that. When I was 13, in 1960, watching TV in a dark room, I stood up and stretched (strained) and walked to the kitchen, where I passed out and my head hit the floor.
In a city of half a million, my GP had me get an EEG which they said was "normal for his age group", and he prescribed Mebroin (methobarbital and diphenylhydantoin), so I took that for a few weeks. I didn't faint again but my mother wasn't happy. She asked the GP for me to see a specialist. He said "Well, if you want to".
So he sent me to a neurologist and he added a second drug. My mother asked him if was habit-forming, and he said, "What do you think we're doing, Mrs. Mother, running an opium den?"
So I took both drugs for a few weeks and my mother still wasn't happy. She asked the GP for a second specialist, and maybe the doctor didn't like that either, but otoh, this time she was second-guessing someone else, the neurologist. I guess my home town didn't have many neurologists because this time I ended up with a neurosurgeon. He had me get another EEG while he was there and he had me stand and stretch, and hopefully pass out. I didn't pass out and the EEG reading was messed up by all my movements, but he slowly took me off both drugs, and that was basically the end of it.
There's another chapter to the story when I was 19 but it's not really on the subject**.
By now you've probably figured out that I never had epilepsy, it was just orthostatic hypotension, which, for the benefit of others here maybe 1/3 of the population has. Light-headed right after standing up.
In defense of the doctor, he never charged us. My mother didn't know why. Maybe because she was a widow, maybe because her first husband (who also died) went to the same med school he went to. I saw the dr's ledger one time and 1/3 of his patients that day he was seeing for free.
My mother said that his wife was rich, but we agreed that that wouldn't stop a lot of people from charging full price anyhow.
He also never required an appointment for anything afaik, Come in that day. OTOH, he would examine my mother with the door open and a clear view from the waiting room. My mother would go over and shut the door, but my aunt wouldn't put up with that and changed doctors.
But it was nice. One time my mother and I are in his office, and I say to him, "I don't think my mother has had her polio booster" and he nods at the nurse who goes to the fridge, gets the vaccine, fills a syringe and hands it to him, and my mother gets her shot, within two minutes of my first words. No charge. (My mother thought polio shots were only for children. She was old enough and should have known that FDR was 39 when he got polio. )
This is distressing but it's good that you warned me. No one else has. I'll be more alert.
I didn't know that either.
My brother's a radiologist at a hospital and I needed an orthopedic surgeon once, and he said, "I don't know who's good. I only know, probably, who hasn't been sued since I've been here. So he referred me to the top-ranking guy. (I ended up not having that surgery anyhow)
Okay. I"ll bear that in mind.
**The final chapter. Six years later, when I was 19 I had a summer job and would spend the coffee break daydreaming. When the break was over, I was often in a stupor and it took a long time to wake myself. When I saw the GP for some reason I told him, and he said, "Do you want to get to the bottom of this, Do you really want to get to the bottom of this", so of course I said yes. And he referred me to a the head of neurology at the U. of Illinois Med School, who had helped in the development of the original EEG. This guy was so busy even his secretary didnt' have time to talk to my mother. ot
But I went. He told me to get no more than 3 hours sleep the night before so he could do the EEG while I was sleeping. At the end he said "You don't have epilepsy and you never did." I told him my blood pressure theory and he called a lab in the building but they couldn't be ready until Monday. His secretary suggested a polygraph, so that's where I went the next day. Before he even started the guy came into the waiting room and told my mother, "Don't worry. We had someone here last week and it was all in his mind." He ended up telling the doctors that I was malingering (though I wasn't.) I saw the report. Several times he misquoted me or quoted me out of context to totally distort what I said. It didn't affect my medical care, but it bothers me if either of the doctors thought I was lying.
This was Leonard Harrelson. He's dead now but he was famous in the world of so-called lie detectors I thought he was the lowman on the totem pole and that's why he was the one who had to come in on Saturday, but actually Keeler had retired and he was head of the company. He was so gung-ho he probably liked working on Saturday. It was the Keeler Polygraphic Institute (so-called) and he was Keeler's favorite guy, who married Keeler's daughter. If you go to Amazon and find the book he wrote and read the reviews, you'll see what a fraud three people say he was. And that was my experience too. Without a doubt. (I've been meaning to add my own review)
That's interesting. AVG Free will do that sort of thing, but one has to change his search engine to something other than google. I forget what.
Right.
If you're healthy, it doesn't seem worth it, until the moment you're not healthy.
OTOH, it didn't help my 79-year old friend, whose concierge doctor did no more than text him back for 3 weeks and recommend chiropractor while he was getting sicker and sicker.
He had the valve replacement on Thusday and it turns out as of yesterday, the infection has spread to other organs, plus he needs dialysis at least temporarily. I'm going to call in a little while and see how he is.
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