Graham wrote yesterday:

Some might argue that these “highly ethical physicians” aren’t so highly ethical by practicing retainer medicine. One ethical framework would suggest if all physicians just practiced retainer medicine, there would not be nearly enough physicians to go around. In that framework, retainer medicine would be viewed as unethical.

(I also don’t really get how Dr. Centor combats the classist and racist arguments he brings up. They’re totally valid, and I can’t help but draw a parallel between retainer medicine and insurance company cherry-picking, the latter I find to be despicable in its bottom-line philosophy. By practicing retainer medicine, you are selecting out for people who can afford to pay extra, and health and SES are intrinsically linked (and also race), so you’re essentially picking out people who are already healthier.

I am delighted that Graham responded as he did. Graham is an idealistic 5th year med student (he spent a year doing research.) He plans to do emergency medicine, currently applying for residencies. He apparently favors a single payer system. I garnered all this information from his excellent web site.

My son was an English major. He often had me read his essays interpreting books or authors. I love his writing style, and noted a common technique that he used. He would start by explaining the simple interpretation of the novel (or poem, or short story), and then use the phrase “on further reflection.” I love that phrase. I believe it applies to our understanding of the retainer medicine movement.

Disclaimer: I only work as an inpatient attending these days (plus multiple administrative roles.) I have never done retainer medicine, and have no personal desire to establish a retainer practice. I am writing from the vantage point of one who has cared for patients and observed health care delivery since entering medical school in 1971.

Most critics object to retainer medicine on financial grounds. They state that the financing of retainer medicine takes these physicians away from the under-served and towards the well heeled. They believe that the only motivation for these practices is money.

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.

Now I know that I am being somewhat hyperbolic, but I believe that I am not exaggerating greatly. I have attended to many teeth gnashing sessions about the future of outpatient internal medicine.

What are the features of the reimbursement system that drive this despair? First, Medicare provides a standard reimbursement for each level of visit. The levels depend on documentation and complexity. However, for our most complex patients, who really need longer visits, we really cannot bill for the necessary time. Second, Medicare does not pay for reviewing labs, contacting patients, phone calls or emails. The only way you can bill is when you see the patient. Third, as goes Medicare, so go the other insurers.

Medicine has become much more complex over the past 30 years. We know more; we can do more; our sicker patients live longer. More patients have diabetes mellitus – which by itself is a complex disease. More patients live with heart disease. Many patients have more than 5 medications, each of which can cause side effects and interactions. We have more preventive measures to order.

We need more time to do our job properly. Time equals money, but the insurers do not pay for our time.

So we go to talks to learn who to keep visit lengths short and improve documentation to improve billings. We avoid telephone calls, because they cost time, and time equals money. We eschew email for the same reason. We avoid open ended questions because they might cost time.

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?

Upon further reflection we should learn from this ongoing entrepreneurial experiment. Why are patients choosing to spend moneys on retainer medicine? I believe patients are smart. They are tired of the relative inattention that most physicians can provide. They want their physician (not a nurse or physician extender) to talk with them on the phone. They want a call as soon as the lab work returns. They want to completely understand each medicine, each test and each consultation.

Many argue that if everyone switched to retainer practice, we would not have enough physicians. I would argue that as retainer medicine grows, it will start to attract medical students and residents. These practices allow work life balance. These practices allow physicians to feel good about the quality of care they deliver. These practices give patients what they desire.

If retainer medicine continues to grow, I predict that some subspecialists will revert to the internal medicine roots and opt for this practice. Retainer physicians develop deep doctor patient relationships.

The major argument against retainer medicine comes from the concept of social justice. Our current system provides no social justice. Single payer systems do not provide social justice. The concept of social justice transcends any individual physician. Perhaps we can reinvent health care around the retainer concept. Perhaps it would cost less than our current madness.

Related posts:

1. In which I respond to angry comments
2. In which I continue my debate with Dr Val
3. Does IM training lead to decrease primary care selection?
4. I disagree with @DrVal – retainer medicine is the answer
5. Retainer medicine – from 7 years ago

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