I also agree that in the current system, retainer medicine is the way to go. If I leave academics and go back to private practice I’ll be opening a retainer style practice. Would that create a shortage of primary care docs? Of course it would. But we’re already headed for a shortage because nobody wants to jump on the primary care hamster wheel style practice. Have you met a retainer style doc that is unhappy? I sure haven’t. They go on and on about how much they love their job & most of them are compensated better as well. If med students started seeing & talking to these guys, they would start going back into primary care again and we wouldn’t have shortage to worry about.

I think part your response to graham regarding retainer medicine is lazy. You state you reject the public policy arguments against retainer medicine as you always take the perspective of the patient, yet you are more than happy to argue that retainer medicine may help save healthcare dollars, that retainer medicine is an experiment which we (both doctors, patients, soceity) can all learn from, and which can save internal medicine. This goes way beyond taking a perspective of sole duty to the patient. Also, rejecting an argument because you take a different perspective doesn’t make the argument less valid. In this particular case, your rejection of graham’s argument against the general applicabilility of retainer medicine because you takes a public health perspective means that you argument can only be valid certain situations– when there is no public. C’mon, you can do better.

I would like to add a thought….
Whether doctors will admit it or not, in the current system they have 2 goals.
1. How quickly can the patient be gotten in and gotten out of the office.
and
2. How to get paid by that patients insurance.

In a retainer system, the insurance company no longer plays a significant role in the payment of the services.
therefore, Doctors are directly responsible to the patient. NOT the insurance company.
so goes the quality of the service.

Why do you consider them separate? Personally, I think it’s this kind of attitude that has facilitated the growth of the insurance industry in the healthcare industry–letting the businessmen handle these integral aspects of medicine, which in the end do dictate the way medicine is practiced. It’s up to us to express how we need to practice, otherwise we’re just treated as if we’re another cog in the wheel.

And caring for patients does promote social justice, by playing our part in healing people. I don’t understand why it wouldn’t–the wikipedia extract does not contradict the two as far as I’m concerned.

If it is a privilege then what makes a physician asking for payment any more unethical than Wal-Mart asking for payment for a loaf of bread and a gallon of milk? Isn’t food and water a basic need of people?

I believe that generally speaking physicians are charitable by nature. I don’t think a patient’s financial status in life matters to a physician as long as that physician can pay his or her bills at the end of the day. So, if the model is successful, DB is right in that there will likely be more students enter primary care and this type of practice and, as a result, physicians in this type of practice will see all kinds of patients.

I just know that personally it is discouraging to be a general internist in private practice at the age of forty looking for an alternate career if a solution to my chosen calling can’t be found. The system is definitely broken and in need of serious repair. This could certainly be a viable option.

All models, even academic indigent care with employment by the state, result in compensation to the physician. The issue at heart is whether physicians should be compensated for their work. I agree that there are no degrees of ethics.

It is “unethical” to run a retainer practice because someone may not be able to afford the retainer, or chooses not to pay the retainer, spending the funds on something else (cigarettes)? Why, then, is fee-for-service medicine “ethical”? Someone may not receive healthcare because he cannot pay the fee, or chooses to spend the funds on something else (cigarettes)?

Like your Hillel Talmud Shabbath 31a, on the side, all the rest is commentary. Is it ethical for a doctor to expect compensation for services rendered? If yes, the rest is commentary. Some may choose fee-for-service, some employed models, some retainer practices. Assuming services paid for are actually delivered. They are all ethical, or none are ethical.