Concierge medicine

So I've been shadowing an internal medicine physician specializing in geriatrics (old people) who works in a concierge setting. The concierge part seems highfalutin, kind of opposite of the internal medicine part. But that's just on the surface. After shadowing her just once, I can see that it actually allows her to give back more to the community, see more indigent patients, but then again, maybe that's just her outlook and maybe she would've done it even if she wasn't in a concierge setting.

Anyway, for those that don't know, because I certainly didn't know before shadowing her, a concierge practice is one in which you pay a flat rate/year to see the doctor. The price seems pretty hefty, $1000-$3000 or more, but a patient of a concierge doctor gets to see him/her whenever she wants, call/email the doctor (and actually get responses), and even have the doctor be there when the patient has to make an emergency visit somewhere or just tour nursing/assisted living homes. Considering all of that, the $1k-$3k is a pretty good deal. For those who require that kind of care.

Here are some things I've noticed from shadowing this doctor, some related to the concierge nature of her practice, and some not:

• Time: One big perk of having a concierge type of practice is simply having more time—time with the patients and time to be a human being for the doctor. I can definitely see this comparing Dr. S's consults (Dr. S=concierge/internal med/geriatrics doctor I'm shadowing) and the visit I had with an ob/gyn recently. Dr. S has a whole hour blocked out for a patient, giving them time to chat about things unrelated to the patient's health (Blackberry vs. iPhone, politics), and most importantly giving the patient time to think if he/she has any other questions, of which there usually are. I know that all of this is the essence of primary care, regardless of what type of practice it is, but I feel like being in a concierge type of setting allows you to develop that essence more—the essence of building relationships with your patients and addressing all the patient's problems, mental, physical and otherwise, in a holistic way.
• Time is funny. It helps define who you are. Because time is limited, everybody has to prioritize. Specialists prioritize their time to focus on being skilled in one narrow subject; internal medicine physicians prioritize their time to take a step back and look at the whole picture, make sure the patient's medications aren't negating each other or having an undesired reaction with another. Specialists vs. primary care…and not just in terms of career choice, but from the health systems point of view.
• Coming back a little to having time to build relationships with one's patients, I feel like that's what Dr. S is really in this business for…and so she prioritizes that and opened up a concierge practice. See how that works?
• Patients: more than meets the eye: Many patients are smart; not all, but many; and not in the same way that you are as a doctor. So that's one reason to respect them, but many if not all of them have gone through a lot of hardships. Ones that you can't even begin to imagine. So respect them, because they deserve it.

So that's all I have for now. I now want to open up a concierge type of practice some day. It's funny how the people you meet really influence what you do later in life and what you want…makes me (almost) believe in fate.

The world is copying me

Just kidding.

But still, I thought I was unique...

• Secretary Clinton's Remarks on Global Health Initiative: "The United States is investing $63 billion - first, to sustain and strengthen our existing health programs, and second, to build upon those programs and take their work to the next level by collaborating with governments, organizations, civil society groups, and individuals to help broaden the improvements in public health that we can expect. We're shifting our focus from solving problems, one at a time, to serving people, by considering more fully the circumstances of their lives and ensuring they can get the care they need most over the course of their lifetimes. ..." (Btw, this speech was actually at the Johns Hopkins SAIS in DC. Crazy. Hopkins represent!)
  
• And this dude...who started a public health education and training program for rural Haitian youth: "I'm striving to be more than just a physician. I want to be an advocate for human rights, a voice for those whose voice goes unheard and a face for the poorest of the poor. I don't imagine myself in a hospital or in a lab. I'm interested in political medicine, changing policy, the way medicine is practiced, the way it is distributed, and how it is defined."
  
• And this other Dr. Francis Collin dude too: "The aim of the [NIH/PEPFAR $130 million global health initiative], Collins told Nature in an interview in July, is 'to build research capacity in African institutions to enable them to begin to play a larger role in studying their own health needs, in providing solutions, because I think the era of the developed world swooping in, doing the research, saying 'here's what you should do' and leaving is not the era we want anymore.'"
• And this dude Nicholas D. Kristof, this chick Maggie Doyne, this dude Professor Peter Singer: "Many people want to connect to a cause larger than themselves, but they are busy and juggling priorities, have limited time and don't know quite what to do. There's a market failure there; so many people who would like to help, and so many people who would benefit from that help, but there's a shortage of channels to connect them...The challenge is to cultivate an ideology of altruism, to spread a culture of engagement - and then figure out what people can do at a practical level."

23-year old Maggie Doyne with her kids at the Kopila Valley Primary School, which she is the founder and principal of.

• And this mere commentator dude on Kristof's article: "I am sad to say that I am afraid you are correct, and Americans will turn back inwards. After 911, it was fear that motivated many, I believe. I think the only way to hope for us to really get it would be for us to learn the real links between our own prosperity and the poverty of so many worldwide..."
  

Poo. :(

Oh well, on the bright side, and the only side that matters, other people are already acting on good ideas and doing good. How awesome is that?

Grateful + frustration

Recently, reading about
        -- the health disparities around the world

Waiting room at a clinic. Cholera epidemic in Haiti because of a lack of clean water system.

        -- the harsh reality of this:

Living as a girl in Kibera, the largest slum in Nairobi, Kenya.

This makes me so grateful for the upbringing I had. And then I think about America's long standing problem with

Obesity.

If I end up being involved with global health as I plan to, I'm wary of the frustration that I might feel with patients who can't keep their weight down. I know it's a complicated issue. Obesity is a result of genetics, the environment, our culture, exercise, etc. etc. I know that every patient has suffered and deserves at the very least a doctor's respect, but on the inside, I fear I will be looking down on them. I will think, there are people fighting for their lives, living in disgrace, and here, you can't find the willpower to keep your weight down.

Every person is a human being.
Yet, I'm a little torn.

Does this make me a terrible person?
How do I deal with this?


Photo credits: Haiti & cholera, Michael Appleton for The New York Times; Shining Hope for Communities

Malpractice litigation + health insurance + Atul Gawande's Better

I've been working my way through Atul Gawande's Better, and as I'm writing this, I realize that I'm more than halfway through, which surprises me a little. I don't feel like I've read that much...sign of a good writer?

I loved his debut, Complications. My boyfriend asked the other day, so is the 2nd book really better? Ha. I'd say it's more serious. By this, I don't mean that Complications dealt with fluff, but the topics that he chose to cover in Better (litigation, health insurance, patient privacy) definitely reflect the years that has passed--and its requisite experiences, feelings, growing bitterness?, definitely growing disillusionment--since his residency, when he wrote his debut.

There are many passages of the book that has stuck with me, but the most recent one pertains to malpractice litigation:

The one defense of our malpractice system is that it has civilized the passions that arise when a doctor has done a devastating wrong. It may not be a rational system, but it does give people with the most heartbreaking injuries a means to fight...And although it does nothing for plaintiffs, people whose loved ones have suffered complications do not then riot in hospital hallways, as clans have done in some countries

When I read that, I thought, Ha, that's what happens in China. Where do I begin? The doctors who get ambushed publicly when loved ones day? The reporters who get maimed for investigating doctor misconduct? The lack of respect and satisfaction doctors in China feel? Reading that passage above made me suddenly wondering, would a better justice/legal system not only help human rights and other areas but also the health system? Just a thought.

Gawande then goes on to talk about health insurance: insurance considerations start from the moment someone calls to make an appointment. Making sure they have insurance, making sure you as the doctor falls in their insurance's network, making sure the insurance covers the visit or service, making sure the patient is aware that he/she has to bring in money for the copay, entering in the right referral number, preapproval numbers, insurance-plan numbers, diagnosis codes, procedure codes, visit codes, tax ID number, etc. etc. Reading it just makes my head spin, I don't want to think about actually doing all of that...Just like Gawande, I've heard from doctors, almost-doctors, and potential doctors alike that insurance is/was their biggest concern. And I can kind of get a feel for that. No wonder concierge practices are getting more popular. More on this later. (I'm shadowing a concierge doctor now.)

Dr. Abraham Verghese

This man is amazing. Another hero to me. Up there with Jim Yong Kim and Suzanne Farrell...he gives me hope and inspiration for pursuing medicine and arts at the same time and finding unexpected but welcome connections between the two.

At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.

Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.” He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

Physician Revives a Dying Art: The Physical

Relevance of today's primary care physicians

Recently, our group at work was hit with sickness: one girl got acute bronchitis, one had a cold, and another probably had acute bronchitis as well but...never went to get checked out, which really is the whole point of this post. From said coworker's adamant refusal (stubborn reluctance?) to go see a primary care physician to a news report about the high percentage of over/misdiagnoses probably due to greater reliance on online sources (WebMD), it seems as if the relevance of health care delivered by primary care physicians (PCP's) is decreasing.

People can easily go to webmd.com to look up symptoms for many diseases like breast cancer and be convinced that they have said disease.

I'm probably exaggerating. Growing up in a frugal yet health conscious family, I've only gone to get check ups from a pediatrician when an external source required it (e.g. school, work). Each time, the check up was very uneventful. I was a normal, healthy girl. And so beyond allowing me to join the school's swim team or to work, those check ups never seemed very worthwhile. So, it's easy for me to say that the services provided by a PCP are not relevant to my life, but it's beginning to feel the same for many other people, too. What do you think?

If people are using PCP's less and less and thus rendering their role less and less relevant to our health, I wouldn't be surprised. On the way to work the other day, I noticed how many radio advertisements there are promoting medication for all kinds of diseases. (Are you suffering from <insert random-never-heard-of-before-disease>? Are you having trouble sleeping? Do you sometimes get up with aching joints? Is your vision getting blurry? If so, you might have said-disease. Miracle-drug-A can help. Ask your doctor about it today!) Listening to these so much, who wouldn't be tempted to over/misdiagnose? I mean, PCP's are still useful because you'll need them to fill out prescriptions, but you can probably get those from specialists, right? Or, even if you do go to your PCP to ask about the disease and medication, the tables have turned: people are not going to their PCP's for check ups or out of concern for an unsettling, persistent symptom, they are going to their PCP with an idea of what their diagnosis might already be, which they make known to their PCP. Does this affect their treatment?

I think so.