Much is written about the advantages for primary care physicians and patients of working within a retainer model, direct primary care, concierge-type care model. Little is written about the downside or disadvantages. It is time to shine a light on the benefits and challenges of concierge and standard models through an experienced lens, particularly as drivers of burnout and the primary care shortage loom so large. The phase of a career may be an important factor.

I started practicing internal medicine in downtown Portland, Oregon, in January 1986 at age 28.

Part of the success of this private practice was a culture of house calls and hospital rounds. I had amazing senior mentors on how to optimize the patient experience.

Due to reputation and location, we saw both the Portland elite and the homeless. By 2005, now working at an academic medical center on the West Coast, I was asked to develop and lead what became the largest at the time concierge practice in academic medicine in the United States. Thus launched my unplanned career as a “concierge internist.” Due to this success, I was recruited to an academic health care system in 2011 to launch a first-ever (and still going strong) concierge primary care practice in an integrative medicine center.

In 2015, due to a second marriage, my professional career moved to Colorado. Within a few months, I was asked to launch a new concierge internal medicine clinic. This clinic is very successful, and yet, by the end of 2017, having launched three concierge programs in three academic health care systems, I stepped away to return to a standard ambulatory internal medicine model. Since late 2017, I practice 85 percent clinically in one of the larger faculty internal medicine practices near my home in Denver.

What did/do I most enjoy about concierge medicine?

• Wonderful work/life balance; schedule flexibility and autonomy.
• Increased time with patients; little to no time pressure.
• Higher salary.
• Increased time to research specific medical diagnosis.
• Time to discuss interesting cases with colleagues.
• Seeing patients same day or next; open schedules.
• Real or imagined, a bit of prestige in the belief we were some of the ‘best’ internists in our diagnostic and communication skills to be given these opportunities.
• Hard to admit ego strokes in the sense of taking care of “really important people.”

What did I not enjoy about concierge medicine?

• We didn’t measure our quality of the care; no outcomes data were collected.
• Some of our peers and specialty colleagues looked down at us, openly critical of the concierge care model.
• I tired of being the medical director; sense of responsibility for growth and innovation.
• Patient text messages came every weekend, based on patient convenience.
• The expectation to answer a patient text or phone call immediately.
• Navigating unrealistic patient expectations and entitlement.
• Feeling like I was part of the patient’s paid “staff.”
• Repressed values clash with my physician oath and low-income roots.
• Inability to take a walk or make love without my cell phone next to me for 13 years (and yes, it would go off almost on schedule).
• I was not seeing enough sick patients. I started to lose skills, like joint injections.

Now back in a standard ambulatory medicine clinic for over two years — what do I enjoy most?

• A clinic with over 10,000 patients and growing to sixteen internists and nurse practitioners. A panel of 1250 patients.
• Integrated behavioral health, care management, palliative care, nutrition, and clinical pharmacy on-site in our clinic.
• Dashboards of my quality outcomes and accountable metrics.
• Many complex sick patients, transplant patients, transgender patients, HIV patients, elderly chronically ill patients.
• Expanding knowledge of new medications (diabetes, anticoagulation, too many to list) with the expertise of the clinical pharmacist.
• Social support of being part of an effective interprofessional team.
• Not being in charge.
• A 10day vacation with not one look at my EHR and zero guilt.
• Sense of value alignment and living my oath in caring for as many patients as I can with the primary care shortage and my own family roots in rural Oregon.

What is still really difficult about standard ambulatory internal medicine? You know this.

• Incredible time pressure with patients; no time to call patients.
• Fighting the sense of inadequacy of not doing enough or not being able to get it all done.
• Working 12-14 hour days to complete all the electronics in basket work.
• Rather than prestige, the sense that the physicians are something between a factory worker and a commodity for the product/profit center health system.
• Full-time salary that is two-thirds of what I made for the past 13 years.
• Feeling tired and stressed quite a lot.
• Frustrated when I cannot get a patient in for timely specialty care when needed.

The ability to completely unplug tips the scale for me to stay where I am for this last decade of my professional career; it might be different if I had twenty years left or children at home.

I am most grateful to have been able to experience these highly variable models of care. I encourage physicians to not look at these choices as lifelong exclusive decisions. One can move in and out. The years in concierge undoubtedly added to my career length in ambulatory internal medicine. Different life phases (raising children) influenced my professional priorities, increasing the value of concierge medicine during that challenging time of work-life balance. With the dawning of reimbursement models based more in population health, I hope for a better future where primary care physicians and patients don’t have to make such difficult choices.

Annie Moore is an internal medicine physician.

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