In which I try once again to explain the public health issue

As a professional, doctors have a fiduciary duty to their current patients to provide good care. Once a doctor-patient relationship is established, there are all sorts of legal issues that arise (this is why ‘Good Samaritan’ laws generally make it clear that a doctor helping someone by the side of the road has not established a doctor-patient relationship). There is no such duty to prospective patients, even though a socially responsible physician may desire to ‘help society’. Arguably, a doctor that takes on a new patient knowing that it will reduce the quality of care to existing patients could be sued by those existing patients. To take a specific example, if the doctor at the district health clinic with 1,750 patients cuts short a visit with an established patient because a new patient is waiting, it would be easy to make a case that he/she has failed the duty to the established patient. In my opinion, that doctor has a duty to refuse to see new patients unless all his/her established patients are receiving the best quality care he/she can provide in that environment (note this does not mean the doctor has to provide MRIs, etc. outside of his/her control, but time spent talking, examining, etc. certainly). The fiduciary duty of a doctor-patient relationship is between the doctor and each individual patient, not between the doctor and society.

Dr. Rich-
I’ve read your comments on your website and agree with your positions. I don’t think retainer medicine is unethical and understand the benefits. But I’ve been critical of db’s arguements because of his failure to formulate a public health/social/political reason for retainer medicine. He insisted that he did not have to because his perspective of patient centered medicine. The problem is that the patient, in this country, is not the primary, up front payer of medical care, and the government is the largest single payer through Medicare. While I theoretically agree with SteveSC that the physician’s primary duty is to the patient (and not society), it is not really the case when the patient almost never pays for his or her health care directly (the third payer has a say, and the patient is too removed from paying out the services). In essence, healthcare reform will become a political battle and retainer medicine will not be of any significance if primary care physicans continue to ignore this aspect– this has been the story of how internal medicine docs got left out. It is highly unlikely that spontaneous market forces (i.e. the spontaneous demand for retainer medicine and a supply of physicians to provide that supply) will lead to reform when the fundamental players in a health care market (doc and patients) are several steps removed from payment. There’s no reason why a patient cannot pay a doctor out of pocket, but retainer medicine still involvs insurances and governments. A larger justification for retainer medicine is needed, and Dr. Rich at least begins to formulate that. An engagement with political forces is important.