Whenever a new idea arises, whenever a new movement starts, one benefits from a clear understanding of the root antecedents. What atmosphere in the medical climate led to the idea and the growing adoption of that idea? Those that blindly criticize the concept miss the point. This idea couldn't arise in a vacuum. As Steven Covey says, 'Seek first to understand, then be understood'.

Let me first define my understanding of retainer medicine (I choose to use this term rather than the term concierge medicine which, in my opinion, immediately labels the concept). The patient contracts with a physician for comprehensive care, and 24 hour access. If the patient needs to see the doctor that day, the doctor can and will comply. The doctor cares for the patient in the hospital, in the office, at the patient's house or on the phone.

Patients want continuity, comprehensiveness, and access. None of my golf buddies are physicians. They want access at their convenience. Often they'll call me in the morning and want a problem addressed that day. I try to help them, when I can, but the current system generally lacks that responsiveness. Last year my 25 year old daughter called me on a Sunday night complaining of an acute illness. I was fairly certain that she had influenza and would benefit from medication. I told her to call her internist the next morning to either get a prescription called in or be seen. Her internist's office said she couldn't be seen until Tuesday. My understanding of the anti-influenza medications says that those 24 hours were very important - she remained ill for approximately a week.

Patients want time with their physician. One physician that works in my division has a great clinical reputation. Her patients commonly tell me that she spends enough time with them and 'really listens'. Unfortunately, you don't often hear physicians described like that.

So we have the first phase of understanding. Patients have difficulty satisfying their needs of continuity, comprehensiveness and access. From the patient viewpoint, I believe that the current system has worsened all these needs over that past 10 years.

General internists are the less satisfied physicians in the United States. When asked they complain about many things, but most complaints center on time and money. Let's address the time issue first. In order to achieve adequate gross income, an internist must see approximately 3 patients an hour, an average of 20 minutes per patient. While some visits really require 10 or 15 minutes, some visits should take 30 or 45 minutes. And the physician doesn't know until the visit starts. What is the internist trying to do? First, one must address any new complaints. Sometimes these come in a long list, often handwritten or typed. Often, the patient has read something on the internet, and wants you to comment. Second, one must address ongoing problems. Each medical problem requires some thought as to how treatment is going, or whether new tests are indicated. One should reconsider each medication, is the dose correct, are there any potential side-effects, could any combination of medications cause an interaction. Third, one considers prevention. Are all prevent issues on schedule? Is it time for new testing? Fourth, one screens for disease. As discussed earlier this week, one should screen regularly for depression. There may be other screening issues related to the patient's underlying diseases. Fifth, one should offer lifestyle counseling and advice. Most patients need dietary and exercise encouragement. Internists rarely invest in show advice, both due to lack of training but more important the lack of time. Yet such lifestyle advice can successfully reduce the risk of diabetes in many of our patients (Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle among Subjects with Impaired Glucose Tolerance - N Engl J Med 2001; 344:1343-1350). Sixth, one often needs to spend a short time listening to the patient's concerns or eliciting feelings and responding. This ideal visit cannot often occur in 20 minutes.

How much does Medicare pay for that visit? $39!!!!! And the office cost more than that to keep open - assuming the physician were independently wealthy and didn't deserve a salary. Thinking, talking, interacting and caring isn't reimbursed in our current system. This angers internists. Internists have wonderful training, handle medical and psychosocial complexity, can provide care for inpatients and outpatients, yet the payors seem to not value what we do. They value a lab test, or a radiologic procedure, or a surgical procedure, but they don't value careful thought. And remember that the time spent is greater than the patient's visit. The internist reviews laboratory data, radiologic data, and gets back to the patient about the tests (at least in an ideal world). The internist responds to phone and email inquiries (no charge). His office receives approximately 2 calls for each actual visit. Someone has to answer those calls, triage the questions, and often the physician either responds or crafts a response. $39!!!!!!!!! Are they serious?

Just to add fuel to the fire, over the past 10 years, governmental bureaucracy makes things even worse. We can no longer charge for looking at a urine sample, or a gram stain, or do a few lab tests (CLIA standards). Our documentation requirements skyrocket each year both for inpatient and outpatient visits. Each insurance company has differing requirements, leading to a plethora of business staff for this office that gets peanuts per visits. ARRRRRRGGGGGGGHHHHHHHHHHH!

From these concerns arose a new concept - retainer medicine. For a fixed fee, the patient has the doctor's total attention. He/she can reach the physician 24 hours a day. The physician cares for the patient in the hospital, in the office, in the home when appropriate, by phone, or by email. If the patient needs a visit today, he/she gets that visit. Such care costs more than insurers pay. Thus, a retainer is required. A sound business concept which allows the physician to practice a more ideal medicine, a more satisfying medicine, a more thoughtful medicine, a more comprehensive medicine. A sound business concept which gives the patient what he/she desires - access, comprehensiveness and continuity.

So what's the problem, why does anyone criticize this concept? I'll try to address that later today. Now off to hospital rounds!