Now that I've framed the problem, it's time to examine the movement. I'll assert that, ignoring the money, patients will prefer retainer medicine. Under this system, patients have greater access and more attention from their physician. This system meets patient desires.

Most internists would relish a retainer practice. The system removes our concerns about time. We can provide comprehensive care, both inpatient and outpatient. We have time to talk to patients, in the office and on the phone. When a consult is needed, we can discuss the patient with the consultant both before and after the consultation visit. One can view the X-rays and discuss them with the radiologist. In short, one need not take short cuts to providing complete care.

If not for the money, this would seem perfect. Even without the money though, we would have problems. The numbers don't work. We don't have enough primary care physicians for all the patients. If I decrease my practice from 2000 or even 3000 patients, to only 600 or perhaps 1000 patients, who will care for the remaining patients?

The pros of retainer medicine are obvious. Patients love the attention, and may even get better care (although we have no data to support that claim). Doctors also love the pace and comprehensiveness. Most internists would prefer a mix of inpatient and outpatient medicine, and retainer medicine allows for that mix. Caring for 600 (or even 1000 patients) allows a better quality of life for the physician. The doctor-patient relationship strengthens which gladdens both doctor and patient. Finally, if we adopted a more widespread retainer model, more physicians would choose general internal medicine and family medicine. The retainer model makes the finances work. This model pays for the time and effort to think through each patient, rewarding the physician's intellectual tasks. Seems wonderful.

Opponents raise several interesting points. First, if I downsize from 2000 patients to 600 patients, what happens to the 1400 patients. Have I abandoned those patients? And do they have another physician to choose .. probably not in today's financial climate. Second, will we create a multi-tiered system. They argue that health care is a fundamental right, and no one should be able to pay for First Class care different from any other patient's care. Third, following that argument, increased adoption of retainer medicine would leave increasing numbers of patients without access to good primary care.

I'll take the side of the retainer movement, admittedly understanding the objections. However, when I chose internal medicine, I didn't chose financial suicide, I chose good patient care. I argue that the system, insurers and the government have forced this movement. If I want to practice ideal medicine, Marcus Whelby medicine, then this may be my only option. If health care is a fundamental right, then the insurers and government (Medicare) especially should reimburse general internists and family physicians a reasonable fee, while limiting costly bureaucratic rules. Individual physicians can't just act altruistically, they have responsibilities to their own health and quality of life. The current system is brutalizing those physicians. Growth of the retainer model will help focus the debate to the true antecedants. We have a health care reimbursement system that is tragically flawed. Critique retainer medicine, deride "concierge medicine", but please think. We need good internists and family physicians. If we don't address the root causes, then we will have less access. You cannot force physicians to choose to practice in the current system. And you shouldn't.