Monday, May 3, 2010

Knope: Internal Medicine Is Dead, Will Concierge Physicians Thrive?

At, Dr. Steve Knope offers his take on the future of internal medicine and concierge medicine in the ObamaCare era.

Here's an excerpt from "Internal medicine is dead, will concierge physicians thrive?":
As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D..

If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the "headache" that is actually an aneurysm, the "flu symptoms" that turn out to be meningitis, or the "gallbladder problem" that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.

As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase.

However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.
I do believe that patients and providers should be able to contract freely for medical services, and this includes so-called "mid-level providers" such as nurse practitioners. But Dr. Knope makes an important point -- namely,that you may not get the same level of care with a mid-level provider than with a MD.

To the extent that concierge physicians are allowed to operate, they potentially offer an excellent value for patients -- personalized service, individual attention, and high quality of care.

And as Dr. Knope points out on his own blog, these medical services can be surprisingly affordable. But he's also right about the wider issue of the corrosion of general internal medicine. The more Americans learn the truth, the better informed they'll be when the next round of health policy debates begin in earnest.