It is counterintuitive, but I think the secret to providing more, is doing less.
Recently, I transitioned from a "traditional" primary care physician to a membership-based one. This means that patients pay a fee to be able to access me and the team. It's along the lines of concierge medicine, although there are several key differences to our Active Health model that make it, in my opinion, superior to simple "pay-for-access" concierge medicine. Among these are our in-house interdisciplinary team, our extreme focus on prevention, and our competitive pricing.
Despite these significant differences in our model, we are still inexorably tied to the reputation of concierge medicine, whereby the physician orders (and the patient expects) dozens of additional laboratory tests, imaging studies, and referrals. If patients are paying for access, they typically demand more.
But we know from our previous examination of the via negativa framework that more testing is not necessarily better, and doesn't necessarily lead to better outcomes. Testing should be ordered only if it fulfills certain criteria:
These criteria rule out much of the testing that is commonly seen in concierge practices and through executive physicals. While it may make the patient (and the physician) feel important to be able to perform and pay for so many tests, it's ultimately an exercise in frivolity, and doesn't change health outcomes.
So how does one balance these two seemingly dichotomous goals? I think ultimately it boils down to two factors: patient education and expectation management.
A significant portion of a primary care physician's time is not in diagnosis or treatment, but in patient education. This must necessarily include education on the via negativa philosophy of medicine, and an explanation of why, in many cases, less is more. This is usually not instinctual for patients to grasp, and may take a significant investment in time.
A patient who understands the intricacies of this discerning approach to testing is an incredible partner in the pursuit of health. An alignment of philosophy and understanding leads to an optimal physician-patient relationship and better health outcomes.
If a patient does not understand the foolishness of ordering every test under the sun, there is little a physician can do to placate them when an appropriately limited number of tests are ordered. The physician-patient relationship may be strained, if expectations are not properly managed.
Expectation management, therefore is the other key to balancing proper care with 'concierge' expectations. Patients must know a physician's philosophy before signing up for a concierge or membership-based practice. This can be through explicit marketing material, through a physician's prior writing or speaking, or through direct familiarity with the physician (such as in a previous clinical relationship). Importantly, patients have a choice in selecting a primary care physician. When the details of that choice are known beforehand, it primes both the patient and physician for a superior clinical relationship.
Therefore, while it is difficult to be a membership-based physician who intentionally does and orders less, it is still feasible to succeed. In fact, I think in the long-term a practice like this is more likely to succeed, simply based on the fact that ultimately it is better for the patient. Physicians who pursue the 'concierge' track must therefore resist temptation and pressure to order everything they can, instead ordering just what they should.
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