Comments on: In which I try once again to explain the public health issue http://www.medrants.com/archives/3432 Internal medicine, American health care, and especially medical education Sat, 11 Feb 2012 15:15:48 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Ernie G http://www.medrants.com/archives/3432/comment-page-1#comment-515189 Ernie G Fri, 04 Jan 2008 19:44:01 +0000 http://www.medrants.com/index.php/archives/3432#comment-515189 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. 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.

]]> By: over my med body! » Retainer Medicine Stats http://www.medrants.com/archives/3432/comment-page-1#comment-515188 over my med body! » Retainer Medicine Stats Fri, 04 Jan 2008 19:04:59 +0000 http://www.medrants.com/index.php/archives/3432#comment-515188 [...] SteveSC’s comment about a physician’s duty to his current patients, which I agree with, but doubt that all physicians would truly close their censuses. [...] [...] SteveSC’s comment about a physician’s duty to his current patients, which I agree with, but doubt that all physicians would truly close their censuses. [...]

]]> By: DrRich http://www.medrants.com/archives/3432/comment-page-1#comment-515187 DrRich Fri, 04 Jan 2008 18:54:16 +0000 http://www.medrants.com/index.php/archives/3432#comment-515187 DB, I have been following your posts on retainer medicine with great interest, and congratulate you for taking this on, and for your articulate explanations of why this "new" practice style is NOT an abomination. I have posted a commentary on this exchange on the Covert Rationing Blog that I hope you will look at - it is too extensive to post here. My goal is to show why retainer medicine ultimately offer a pathway toward restoring - rather than threatening - public health. DrRich Http://covertrationingblog.com DB,

I have been following your posts on retainer medicine with great interest, and congratulate you for taking this on, and for your articulate explanations of why this “new” practice style is NOT an abomination. I have posted a commentary on this exchange on the Covert Rationing Blog that I hope you will look at – it is too extensive to post here. My goal is to show why retainer medicine ultimately offer a pathway toward restoring – rather than threatening – public health.

DrRich
Http://covertrationingblog.com

]]> By: The Covert Rationing Blog » Blog Archive » On the Transcendant Importance of Retainer Medicine http://www.medrants.com/archives/3432/comment-page-1#comment-515186 The Covert Rationing Blog » Blog Archive » On the Transcendant Importance of Retainer Medicine Fri, 04 Jan 2008 18:43:14 +0000 http://www.medrants.com/index.php/archives/3432#comment-515186 [...] thread that continues to dangle, however, and while DB has addressed it on more than one occasion (the most recent being today), judging from the commentators who have responded so far, DB has failed to convince at least some [...] [...] thread that continues to dangle, however, and while DB has addressed it on more than one occasion (the most recent being today), judging from the commentators who have responded so far, DB has failed to convince at least some [...]

]]> By: Bad Medicine » Have I been constructing strawmen? http://www.medrants.com/archives/3432/comment-page-1#comment-515177 Bad Medicine » Have I been constructing strawmen? Fri, 04 Jan 2008 17:21:28 +0000 http://www.medrants.com/index.php/archives/3432#comment-515177 [...] says DB, in a very nice response to my post [...] [...] says DB, in a very nice response to my post [...]

]]> By: SteveSC http://www.medrants.com/archives/3432/comment-page-1#comment-515172 SteveSC Fri, 04 Jan 2008 15:44:49 +0000 http://www.medrants.com/index.php/archives/3432#comment-515172 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. 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.

]]> By: Ernie G http://www.medrants.com/archives/3432/comment-page-1#comment-515169 Ernie G Fri, 04 Jan 2008 15:29:47 +0000 http://www.medrants.com/index.php/archives/3432#comment-515169 db: One thing that is left out of your argument is patient demand for these clinics. I don't mean demand as in "I want it"-- I am sure eveyone would like the idea of having a doctor spend more time on them, but rather economic demand as in "I'd be willing to pay x amount of dollars for that time". I understand there are a few retainer practices out there, but their mere presence doesn't prove the demand for retainer medicine is enough to think that it could increase supply of physicians. I am not against retainer medicine, just the idea that it will improve health care significantly (by either by improving the lifestyle of physicians and increasing supply, reducing consultations and costs, or improving quality) because retainer practices will be on the margins of health care. Now you can argue that your only perspective is the patient, and from that point of view retainer medicine is probably superior, but to argue that this is a solution to the primary care shortage now takes you away from the patient perspective to a social/public health perspective. My beef with your critique of your critics is that you have a tendency to argue that your primary perspective is to patients and that everthing else is an externality which you claim you don't care about. db: One thing that is left out of your argument is patient demand for these clinics. I don’t mean demand as in “I want it”– I am sure eveyone would like the idea of having a doctor spend more time on them, but rather economic demand as in “I’d be willing to pay x amount of dollars for that time”. I understand there are a few retainer practices out there, but their mere presence doesn’t prove the demand for retainer medicine is enough to think that it could increase supply of physicians. I am not against retainer medicine, just the idea that it will improve health care significantly (by either by improving the lifestyle of physicians and increasing supply, reducing consultations and costs, or improving quality) because retainer practices will be on the margins of health care. Now you can argue that your only perspective is the patient, and from that point of view retainer medicine is probably superior, but to argue that this is a solution to the primary care shortage now takes you away from the patient perspective to a social/public health perspective. My beef with your critique of your critics is that you have a tendency to argue that your primary perspective is to patients and that everthing else is an externality which you claim you don’t care about.

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