Physicians go into medicine because they want to make a difference, and it is the daily opportunity to help patients that keeps many of them going. Yet today many worry that their contribution is diminishing, and more and more physicians are reporting burnout. Many factors are responsible: increasing productivity demands, decreasing amounts of face time with patients, and a growing awareness that they are spending more time on activities such as record-keeping that don’t enhance their patients’ health.
Such concerns sound especially familiar to many of the 210,000 or so U.S. primary care physicians, a group that includes family physicians, general practitioners, general internists, general pediatricians, and geriatricians. Though they comprise less than one third of all physicians, they account for half of all physician office visits, and for most patients, they are the physicians of first resort. Yet morale is declining, and at a time when many experts foresee a need for an additional 50,000 primary care physicians in just 10 years, the outlook for the patients and communities they serve is not bright.
Consider the case of Dr. Frederic Becker, a general internist practicing outside of Philadelphia. After graduating from Stanford University, he attended the University of Pennsylvania School of Medicine. Instead of pursuing a career as a specialist, he chose general internal medicine, and now practices in a small group of four physicians.
“The amount of time physicians like me spend with a patient has trended downward, and new physicians may be spending as little as eight minutes with each patient," he said. "Time is eaten up filling out electronic forms, instead of really interacting with the patient, and many of us find ourselves spending more time looking at a computer screen than we do at the person we are caring for. Also, many of the organizations that employ physicians are applying pressure to work faster, driven at least in part by a desire for more revenue.”
Becker reports that his practice has never dropped below an average visit of 15 minutes per patient visit, but to sustain it, he has paid a substantial price. “I spend two to three hours a day outside of patient care on paperwork and phone calls,” Becker told me. In order to preserve what time he has left, he has had to spend more money. His small practice has had to hire a full-time employee just for billing and coding. It also invested in a new electronic health record system, which requires maintenance and annual upgrades.
When I asked Becker if anything has gotten better over the past few years, he had to give it some thought. “Well, I guess it is making me a better typist. And I do have to admit that the electronic health record does make it easier and quicker to find some kinds of patient data.” He quickly added, “But make no mistake about it. In my mind and the minds of many of my colleagues, the loss of time and attention has harmed the individual patient at the point of care.”
So Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.
When patients get admitted to the hospital, Becker will remain their physician, and their health insurance will still pay for much of their care. Will it make more money for physicians? Becker doubts it, but if it does, he plans to plow any additional income he might derive back into his group practice, helping to lessen the economic pressures on his colleagues.
The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.
“The work won’t be any easier,” Becker says, “but I will be able to spend more time with my patients, build better relationships, and provide better care. And there is mounting evidence that such practices produce better outcomes, such as reductions in hospitalization rates.”
Of course, there are drawbacks to concierge practice. For one thing, some patients cannot afford it, and others will choose not to pay the fee. Critics also see such models as promoting a two-tiered system of healthcare, in which those with more money get better care.
“But we have always had a two-tiered system,” Becker counters, “and it is better to care for 600 patients well than just adequately for three or four times that number. Someday patients, physicians, and healthcare payers will recognize that slower-paced but truly high-quality medical care is a better value than the fast medicine many physicians feel pressured to practice today.”
Concierge medicine is Becker’s way of tapping into the best of medicine’s past to chart a brighter professional future. “I remember how my father, who is also my former partner, practiced medicine,” he says. “He would spend an average of 15 minutes per visit, and 14 of those were focused on the patient. Then at the end he would make a few notes on a three-by-five card. He didn't need a huge medical record, because he knew his patients, and he didn't allow himself to be rushed if the patient needed more time.”
By adopting a concierge model of practice, Becker is trying to expel an expanding cast of characters who have interposed themselves between patients and physicians: people with forms to be filled out, stopwatches to be obeyed, and cash registers to be fed. He hopes to build a future in which only one person will be in the room with every patient—the physician—and every physician will be free to practice with the level of patience and dedication they believe good medicine requires.