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I never wanted to be a formal concierge doctor. Most of us are familiar with those plans that make physicians limit their patient panel to several hundred patients, and each one of them agrees to pay several thousand dollars for the privilege of access to their physician at all times.
Sure, after over 30 years of practice in the same community, having a smaller patient panel, dedicating more time to each one, and slowing down was definitely appealing. The thought of letting go of most of my longtime patients was not. And so I plugged along.
But a funny thing happened over a year ago. Our healthcare system installed a shiny new electronic medical record (EMR) system with all the bells and whistles -- a huge improvement over our old one. Of course, this included a patient portal. Patients would have immediate access to all of their lab results and could send messages directly to their physician.
"What a great idea," I initially (naively) thought. Reality provided a rude awakening.
Over the past year, I've come to understand the meaning of this arrangement. Patients, unwittingly but understandably, use the portal to feel free to ask all kinds of non-urgent medical questions 24 hours a day, 7 days a week. "Should I take that new RSV vaccine?" "Do I really have to stay on that aspirin since my heart attack was years ago?"
I recently had a patient send me a link to several articles in the lay press that related to his heart disease, and he wanted to know my thoughts. When I politely answered that we could discuss this matter at his next office visit and suggested that this was not an appropriate use of the patient portal, he became indignant because his next appointment was 6 months from now and told my staff he may need to find another doctor. I silently agreed. He should find a real concierge physician who would provide the type of service he demands for a fee.
Educating several thousand patients on the appropriate use of the portal is going to take a long time. And undoing a precedent that has already been established may never occur.
Primary care physicians bear the brunt of these unrealistic demands more than our specialist colleagues do. Is it because we are the "star quarterback" of their medical team? (Who, by the way, oftentimes gets paid less than other team members. Tom Brady read this line and audibly gasped, "What the ...!?") Or is it because we deal with a larger, oftentimes more complex, amount of data compared to others? (Specialist: Bone. Broken. Fix it.)
No doubt, we live in a society of instant gratification, which implies that immediate patient access to their results leads to the expectation of immediate interpretation and feedback by the ordering physician. Reasonable from the patient's perspective. Not so from a physician's perspective.
A patient who dropped off a urine sample late in the afternoon expected me to send in the antibiotic first thing the following morning, even though I had not had a chance to view those results. Many patients who see a number of red flags on their lab reports understandably don't want to wait for their office visit in several weeks for them to be reassured that nothing serious is wrong. "Do I have something seriously wrong since this AST or ALT result is low?" "My BUN is one point above normal and appears in red. Do I have a kidney issue?" And on and on it goes. Patients' expectations clash with the physician's ability to meet those standards.
Sure, expanding the medical team to include more advanced practice providers and taking the burden off physicians is one obvious solution. However, healthcare organizations argue that their resources are limited these days and that they are unable to do so. And from a purely economic point of view, why would they? They can rely on the conscientiousness of primary care physicians to provide free labor to their patients on nights and weekends.
As so many of us can relate, here I am today as a primary care physician being a concierge doctor to several thousand patients. Working harder. Sacrificing my personal time. We've unknowingly accepted all of the responsibilities and expectations, but without any of the benefits. Is this arrangement fair to physicians? Is it sustainable in the long run?
On second thought, let me see that VIP concierge physician contract.
Armand Rodriguez, MD, is an internal medicine physician.
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