Apologies to Mark Twain, but reports of the death of private practice are somewhat exaggerated. There are still plenty of us around, and most of us are making out quite well. Not all, though. I’m quite sure the murmurs of discontent have reached many ears by now. So much so that many doctors unhappy with the status quo have taken action. One such action is to “go concierge.”

Concierge practice, also known as retainer medicine, is basically an arrangement where the patient pays a fee up front (generally quoted as an annual figure, often payable in monthly installments) for the doctor’s professional services.The idea is that for their usually rather hefty annual payment, the patients receive “enhanced” services, most often as longer, more leisurely office visits, and greater access to the physician, typically his cell phone number.

Here’s the thing: I’m already doing all that. Standard appointments are thirty minutes: longer if you need them, same day if necessary. As for my cell phone, all you need to do is ask. Actually, if you want me to text you with test results, you’ll have my cell number forever after. No one has ever abused it, just like my residency director told me thirty years ago (though he was talking about the home phone number: same idea.) Leisurely appointments whenever you want them and total access all the time.

Ah, but what am I getting paid for all this, you ask? As long as I’ve been in practice, I’ve taken almost all insurances. How do they pay? Put it this way: I’m not getting rich, but I’m not starving. Still, I’m providing concierge level care at insurance prices. Why do I keep doing it?

After all this time I’ve amassed an incredibly diverse patient panel (even though I don’t know how big it is) encompassing a wide span of socioeconomic class. Working class folk, professionals, white and blue collar workers alike are equally welcome. I can’t afford to give away a lot of free care, but once you’re an established patient, I’ll work with you on payment issues for as long as you need. I like it this way. Just as family medicine doesn’t limit me to one organ system, gender, age, or set of diseases, taking all insurances provides me with a further variety of patients; people from all different income levels and walks of life.

That means one big reason not to go concierge is so as not to betray the 99 percent, or whatever fraction of my patients couldn’t afford the annual fee. Besides, the actual transition would be nigh impossible, since I’m not sure what more I could do in the way of “customer service” than I already am.

There’s another more subtle issue, though, that I’ve seen more outside the office setting; mainly from friends who have signed up with concierge doctors. The amounts of money involved tend to create an entitlement mentality, shifting the physician into more of a servant role, running the risk of compromised medical care. My concern is hearing a patient say something like, “Hell, for $2,000 a year, the least you can do is give me some goddamned amoxicillin.”  Frankly, dealing with stuff like this scares the crap out of me.

I’ve actually looked into concierge, finding out exactly what’s involved. I spoke with a reputable company, including many doctors who were pleased with them and were incredibly happy with their new practices. I thought about it long and hard. But in the end, the two things above (deserting my patients, and dealing with newly enhanced entitlement issues) confirmed that this is not the right model for me.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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