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Why does nobody talk about the real problems with health care today?

Fam Pract Manag. 2002;9(9):15

For a while this spring and summer, boutique medicine appeared to be a hot trend. At least the media thought so. The AAFP fielded what seemed to be endless calls from magazines, TV and radio contacts, and newspapers about the rise of new “boutique medicine” practices. You would have thought there were no other issues of concern in health care.

What happened to the more than 40 million uninsured Americans, many of whom lack access to basic care and for whom illness means a trip to the emergency room when they can no longer delay care? They have not become invisible, have they?

The lure of the boutique

A boutique practice, for anyone who spent this past year under a rock, is one that accepts limited numbers of patients and offers increased levels of service. Typical boutique services include unlimited access to your physician anytime day or night, immediate access appointments, research on complex or rare diseases, coordination of care with specialists, guidance through a hospitalization, complex executive physicals and other amenities designed to appeal to a wealthy clientele. For this level of service these practices charge hefty prices, perhaps as high as $20,000 per year. (Of course, many of the “boutique” services are ones that we, as family physicians, provide routinely. We coordinate care with specialists, we provide guidance through a hospitalization whether we are primarily responsible or not. Most of us would readily research a rare disease for a patient. It’s simply what we do.)

Boutique practice physicians are said to reap such benefits as the opportunity to care for fewer patients with longer visits and less paperwork. Instead of a typical panel of 2,000 to 3,000 patients, such physicians may care for perhaps 400 patients per physician.

With the current level of dissatisfaction among family physicians, such practices may sound appealing. To many, such as one of my friends in Alaska who is working 12-hour days and taking call every other night, this must sound like a welcome relief. But, somehow, I don’t see many family physicians opting for this route.

Outside the boutique

Boutique medicine may be rewarding for physicians, and it must be appealing to patients who can afford it. But is it right? When millions in our country are uninsured or underinsured, the practice of limiting one’s panel to the wealthy seems to be at odds with the very core of physician values. I cannot reconcile our commitment as physicians with the effort to maximize income by concentrating on wealthy patients. We became physicians to care for people. When we cease to act as though our mission is to care for all people, then we have lost our soul.

I am not suggesting that we, as family physicians, must sacrifice our financial well being to selflessly care for the poor. Certainly, medicine is a business, and it must be sustainable as a business over the long term. The reality of early-career burnout and failed practices is far too real to permit easy and glib posturing around this issue. But we must not give up the dream of high-quality health care for every person in this country, preferably delivered and coordinated by a family physician. We cannot continue to ignore the dysfunctional, expensive and inequitable system by which we care for patients.

We must find ways to make practice livable, sustainable and, most of all, fun. To succeed in this, we cannot spend all our time talking to Mr. Jones about the implications of his hypertension or advising Mrs. Smith about options for treatment of her cancer as we might want to. We must also delve into the business of health care. We must say no to contracts that do not cover expenses. We must engage the Centers for Medicare & Medicaid Services in meaningful and detailed discussions about the problems of Medicare.

We must work to make the health care system work. Yes, there are bigger problems than boutique medicine in this country. The elephant in the room is a dysfunctional health care system that costs too much, cannot care for many of our citizens, and produces outcomes that rank 37th among the nations of the world. The public, our legislators, and the media should be talking about real problems, not boutique medicine.

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Copyright © 2002 by the American Academy of Family Physicians.

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