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
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
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
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
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
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
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
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
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)
(Amazon.com product link shortened)
click on reviews. OR
(Amazon.com product link shortened)
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.
Christopher A. Young
learn more about Jesus
My Norton antivirus flagged your link.
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
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.
We picked up a new doctor we like.
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
If you're healthy, it doesn't seem worth it, until the moment you're
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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