Advantages of my Concierge Medicine practice
I have been practicing Internal Medicine in Miami Beach for over twenty years. In that time, my goal has been to create the optimal practice for patients. I learned very quickly the standard Internal Medicine model, a fifteen minute office visit, did not afford me with enough time to properly care for my patients and solve their problems. As a solution, I was one of the first doctors in the city to adopt the Concierge Medicine model. Simply put, my patients subsidize my practice with an annual fee - this ensures I spend more time with fewer patients. My annual fee is $6,000; my practice is limited to three hundred patients; and I typically only see two to four patients per day. This simple model frees me from the constraints of time, insurance, and conflict of interest. Properly applied, Concierge Medicine has many advantages over traditional practice.
My practice is small. It gives me the opportunity to get close to my patients. Every patient is important. Every patient is unique. No problem is too big and no problem is too small.
Having access to your doctor is more than just convenient. It leads to better outcomes. A patient with access is more likely to communicate with their doctor at the beginning of symptoms. This leads to earlier diagnosis and earlier treatment. In my practice, there are no barriers to communication. You can contact me directly and when it is convenient for you. There are no barriers to appointments. Same-day appointments and even house calls are offered.
Continuity of care is an essential component of your healthcare. It is defined by having the same doctor over time - the same doctor from year to year, visit to visit, and phone call to phone call.
There are several direct benefits of having the same doctor over time. Information continuity - your health records are collected and accessible in a central location. Management continuity - plans for tests and treatments are followed through and chronic conditions are monitored. Relationship continuity - with time your doctor begins to accumulate knowledge about you - your values, your passions, and your fears. Knowledge difficult to record in a chart, yet key to making good medical decisions. Putting all of this together, data from observational studies suggest that patients with good continuity of care have better health outcomes. These outcomes include: greater patient satisfaction, increased adherence to medication, reduced hospital use, and ultimately reduced mortality.
The following scenario depicts an example of poor continuity of care. David has a long history of episodic chest pain. Extensive testing reveals it is not related to his heart and is likely due to anxiety. Over the weekend, he experiences a particularly severe attack and decides to call his doctor's answering service. His regular doctor is not on-call and instead, he is connected with another doctor. She tells him to go to the ER, not knowing his history or having access to his chart. She views David's chest pain as a heart attack until proven otherwise. Why take a risk or expose herself to litigation? The ER doctor treats the situation similarly; David gets admitted for a full workup and testing in the hospital. This exposes him to the dangers of unnecessary testing, a hospital stay, and ironically, more anxiety. The entire incident could have been avoided had he spoken with his regular doctor in the first place.
The 'Executive Physical' is another example of poor continuity of care. An executive physical usually entails a patient flying to another city for an extensive annual check-up with a large battery of tests. As a resident in Internal Medicine at Mayo Clinic and Cleveland Clinic, I have helped conduct many of these evaluations. The problem is that from check-up to check-up the patient is assigned a different doctor, and in-between check-ups the patient lives in another city. Consequently, the doctor who knows the you best is not present when you need them the most - when the you become ill between check-ups.
The low volume of patients in my practice ensures there are no lapses in continuity of care. My staff and I have ample time to maintain your health records and follow through with plans. I do not require phone coverage from other physicians. I am reachable 24/7/365 and never shut down my communication devices. I am always there to bridge the gap between you and the rest of the medical world less familiar with you.
Efficiency is defined as solving problems using the least amount of time and resources and the least number of steps. If you have a medical problem, the traditional Fee-for-service Models can be very inefficient. It incentivizes the doctor to draw you into the office for a face-to-face visit because an office visit is the only way to bill your insurance. Yet, once you are in the office, the Fee-for-service model disincentivizes the doctor to diagnose and treat your problem. He gets his small office fee whether he solves it or not. He is not rewarded for spending extra time, nor does he want to take on the medical-legal risk of diagnosis and treatment. Instead, the work and risk is offloaded by referring you to a specialist. This delays diagnosis and treatment, leads to additional time-consuming tests and visits, and exposes you to the bias of the specialist. This is inefficient and poor use of your time. Quite unfortunate, as the majority of medical problems are common problems. They include: headache, backache, fatigue, cough, diabetes, and hypertension. They may take more than the typical fifteen minute visit to diagnose and treat, but they are well within the scope and training of a primary care doctor.
The Concierge Medicine Model based on an annual fee, rewards me for solving your problems - and solving them efficiently - not for the number of face-to-face office visits I rack up. I want to make the best use of your time. For example, we can skip the office visit if it's only purpose is to bill your insurance. You don't have to come in to review blood tests when this can be conducted over the phone. If you have a rash, send me a picture. To review your blood pressures, text me your latest Bluetooth blood pressure cuff results. I try to employ technology and telemedicine whenever and wherever possible. Common problems are not punted off to specialists and the diagnoses and treatment come without delay.
Medical school emphasizes the pharmaceutical and surgical management of acute medical problems. As a consequence, the primary care doctor starts practice with marked knowledge gaps in preventive medicine and the management of chronic disease. It has taken me over twenty years of experience to fill in these gaps and offer a comprehensive approach.
In addition, a doctor must experience an adequate volume of cases. Prior to Concierge Medicine, I practiced general Internal Medicine for ten years in a high volume practice seeing twenty to thirty patients per day. This volume was necessary for my development as a physician; it sharpened my diagnostic skills, and allowed me to follow the real-world outcomes of thousands of patients. Doctors that come straight out of residency to practice Concierge Medicine, never seeing more than two to four patients per day, miss this critical learning period.
If you want to learn how long your doctor has been practicing, where they were trained, their Florida licensure status, their board-certification status, and medical malpractice claims against them, go to the Florida Department of Health practitioner profiling page.
Accurately diagnosing disease and making important medical decisions requires a tremendous amount of cognitive effort. In fact, accuracy starts to wane in professionals with excessive case loads or long office hours. This is known as decision fatigue. It was first observed in the 1990's with Interns working in hospitals. When sleep deprived, they make more diagnostic errors. More recently, studies have also demonstrated decision fatigue in primary care doctors. At the end of a busy day they tend to: prescribe more unnecessary antibiotics and opioids, forget to offer vaccines, mammograms and colonoscopies, and neglect to wash their hands.
Accurate diagnosis and treatment also depends on your doctor's knowledge base. However, medical knowledge grows at an exponential rate. It becomes out-of-date almost as fast as it is learned. The doubling time of medical knowledge was estimated at 50 years in 1950, it accelerated to 7 years in 1980, 3.5 years in 2010, and is projected to be 73 days in 2020. It turns out that medical school is just the beginning of learning for a doctor. An overworked and stressed doctor has no time to update their knowledge base, and consequently, their knowledge becomes obsolete shortly after leaving residency training.
The practice of Concierge Medicine remedies both of the above problems by lowering case loads and setting reasonable hours. Seeing two to four patients a day ensures that I come to your appointment on eight hours of sleep, enthusiastic, and with enough time to make accurate diagnoses. To update my medical knowledge base I allot several hours per day to learning. In fact, I spend a third of my time reviewing the current medical literature, reading further on difficult cases. and preparing my educational emails and lectures.
No Conflict of Interest
For people who practice medicine there is a deep desire to make patients healthy. It is the one passion that unifies us all. It comes from our hard-wired human instinct to care for one another, and has been woven into our medical code of ethics since Hippocrates. Sadly, the current Fee-for-service Model presents a conflict of interest for everyone in healthcare - from neurosurgeons to acupuncturists. The model reimburses the practitioner for each visit and each treatment - not whether the patient is getting better. In fact, the sicker the patient can be made to look, the better. The more tests ordered, the more diagnoses made, and the more treatments justified. Whether it be an unnecessary cardiac stent recommended by your Cardiologist or an unnecessary supplement sold by your Naturopath. Treatment failures or side effects are not viewed as negatives but opportunities for more testing, office visits, and treatments. When compounded with the medical-legal pressures to do more testing, it's easy to see how we are facing the crisis of overdiagnosis, overtreatment, and a cascade of complications and side effects.
Aside from the direct financial compensation doctors get from testing, medications, supplements, equipment and procedures, the industries that provide these goods and services have other ways to entice doctors to use their products. They spend billions of dollars marketing to doctors which is not money wasted. Research has shown that this Pharmaceutical company marketing actually alters doctors prescribing habits. In addition, the medical industry can entice doctors with direct compensation; such as: being paid "consultants", giving lectures, and performing research. Shockingly, Pharmaceutical companies have even penetrated the academic institutions. For example, doctors at Sloan Kettering where were being paid millions of dollars by the Pharmaceutical industry and not disclosing the financial conflict of interest. This is particularly disturbing because the academic physicians are the "experts" and "thought leaders" that tell the rest of us how to practice medicine. They are the ones that make up the expert committees that draw up our guidelines of practice. In fact, 75% of expert panel members have been shown to have a financial conflict of interest. The government is finally acknowledging this problem with the Sunshine Act. It makes public knowledge any payments to doctors from Pharmaceutical and device companies. You can search the database to check how much your doctor was reimbursed last year. Alternative medicine, with out-of-pocket testing and services, is currently exempt from this scrutiny and regulation; these practitioners may receive even more compensation from industry and have even greater financial conflicts of interest - its hard to say.
To be clear, I am not trying to demonizing any healthcare professional or other players involved in the healthcare industry. All of the players involved are just responding to the incentives - poorly designed incentives.
The Pay-for-performance (P4P) Model, on the other hand, is an innovative way of reimbursing doctors. It incentivizes good patient outcomes. The more healthy the patient, the more the doctor is reimbursed, regardless of how many visits, tests, or procedures are performed. It aligns the financial incentives of the doctor with the goals of the patient. Real world NIH studies of this model are promising and show that it leads to better patient health. The Concierge Medicine Model is essentially P4P. I generate income solely from an annual concierge fee. There are no financial incentives for more visits, tests, or procedures. I have no sources of income outside of my annual concierge fee. No sale of supplements. No links to laboratories or imaging centers. No links to device or pharmaceutical companies. And no links to medical start-ups or hospitals. My goal is simple - keep you healthy and happy. Give you unbiased information to help you make the best decisions. If you are satisfied with my performance you will renew with me the following year.
Like all physicians, specialists are prone to financial conflicts of interest. However, they are prone to a bias of their own - the specialty bias. They naturally view their specialty and the tools of their specialty positively. As the famous psychiatrist Abraham Maslow once said, "I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail". Specialty bias can be clearly seen in the treatment of prostate cancer. According to well done studies, there is no difference in outcomes or side effects between radiation therapy versus surgery. Despite this, when specialists are surveyed, the vast majority of radiation oncologists recommend radiation therapy while the vast majority of surgeons recommend surgery.
Specialty bias can also be seen in the many approaches to back pain. The Spine Surgeon will fix mechanical defects seen on MRI with surgery, the Chiropractor will fix vertebral subluxations with a spinal adjustment, the Acupuncturist will unblock the blocked Chi by inserting needles into the appropriate meridians, and the Physical Therapist will treat muscle imbalances by strengthening weak muscles and stretching over-activated ones. Which one actually works? Ironically, the worst person to ask is one of these four specialists. Imagine, if you will, the Chiropractic theory of vertebral subluxation was proven wrong - adjustments do not help back pain. The Chiropractor would be last to tell you. After all, his livelihood depends on it working. Like all specialists, he has created an echo chamber. He is surrounded by other Chiropractors, Chiropractic specialty journals, and patients that love Chiropractors. When evidence comes his way, he tends to accept evidence that his specialty is correct and ignores the evidence that his specialty is wrong, regardless of the quality the evidence. It is a common cognitive error known as motivated reasoning. As the famous American author Upton Sinclair once said, "It is difficult to get a man to understand something when his salary depends upon his not understanding it."
This is where peer review comes in. Peer review is the process by which a knowledgeable person (a peer), with no skin in the game, renders an opinion. There are two basic prerequisites to peer review:
First, the peer reviewer must be objective and willing to change their beliefs based on a new or a better understanding of evidence. As a General Internist, my livelihood does not depend on Surgery or Spinal Adjustment or Acupuncture or Physical Therapy. As a result, I am perfectly willing to drop or accept any of the four theories based on good quality evidence. I only have one concern - how to get you better. Be wary of primary care doctors that sell supplements, offer Acupuncture, become a Homeopath, or practice Functional or Anti-Aging Medicine. They have become specialists and should be viewed as such. They promote a pet idea or procedure and have skin in the game. It is difficult for them to remain objective and provide peer review.
Second, the peer reviewer must be a "peer" to the specialist. Meaning, he must have medical training to be able to evaluate the claims of the specialist. Without adequate training the novice is vulnerable to the specialist, who can easily win them over with technobabble, testimonial, and reputation. Unfortunately, many patients, abandoned by their overworked primary care doctors, do their own peer review - a serious mistake that can lead to bad outcomes.
It has taken me over twenty years to build the resources in my practice to ensure optimal peer review. These include: maintaining a comprehensive knowledge base to be able to challenge any specialist, having no conflicts of interest to remain objective, and finding a group of exceptional specialists pre-selected for their openness and integrity. During the peer review process, I review the recommendations of the specialist and challenge them if necessary. Claims must be backed with evidence. Peer review is one of the most important roles of a primary care doctor; it is your best defense against the conflicting interests of others. Unfortunately, due to the increasing complexity of medicine and the labour intensive nature of peer review, it is becoming a lost skill in modern primary care practices.
It is essential for you to know all of your options when making a medical decision. Although medical school is exceptional at teaching doctors the pharmaceutical and surgical options for acute medical problems, it is notoriously weak at teaching the management of chronic disease and non-pharmaceutical options. For example, it is very easy to prescribe Ambien for a patient that complaints of chronic insomnia. Yet, there are many treatment options aside from pharmaceuticals. These include: supplements, meditation, exercise, sleep hygiene, stimulus control, sleep restriction, progressive muscle relaxation, and cognitive behavioral therapy. Some of these can be as effective as Ambien although they are time consuming to teach. The current fifteen-minute office visit would not allow for an adequate exchange.
Doctors are also ill-equipped at addressing options from domains not formally investigated by science. They are uncomfortable with questions like: "Should I try human growth hormone and testosterone shots to stay young and fit?", "Will stem cell injections help my knee pain", "What foods will make me smarter?, "Will Accupuncture help my headaches?" or "How does energy healing really work?". To get answers to these difficult questions, patients turn to internet searches or clinics that directly profit from these services. Unfortunately, the information is biased and unreliable (see my post on Stem Cell Clinics and Parkinson's Disease).
From pharmaceutical options to non-pharmaceutical options, and science-based medicine to topics not investigated formally by science, my goal is to present you with all your possible options. It requires a physician with a comprehensive knowledge base. I have accomplished this with my low volume practice, allotting myself several hours of learning per day over the course of 20 years. There most also be adequate time in order for me to teach you all of these options. Once again, this is accomplished by my low volume practice that leaves us with all the time necessary.
A comprehensive approach can produce an inundation of medical options. You have likely noticed this when attempting to investigate health topics on your own. Think about the plethora of supplements that are promoted to be safe and effective. In actuality, there are 87,000 supplements currently on the US market, each one claiming to be safe and effective. Each one also claiming to be backed by scientific evidence. This should engage critical thinking and launch more questions than answers. How do they have no side effects? How can all 87,000 supplements? How do I discriminate the ones that work from the ones that do not? What do they consider "scientific evidence"? Who is regulating all of this?
Learning critical thinking is the most essential, and at the same time, the most difficult skill to acquire in the practice of medicine. It is the key to determine whether any one of the thousands of medical claims or treatments is likely to be true or false. The first step is to develop a systematic approach. This means that all claims need to evaluating on equal footing. There should be no preference given to one claim or treatment over another based on allegiance or personal affixation. No claim or treatment that is preferred because an authority figure professes its benefits. As the Royal Society said in 1660, 'Nullius in verba' meaning 'take nobody's word for it. The next step is to clarify the claim: what is the treatment claiming to do? Is it a specific claim that can be measured or a vague claim? Are we measuring something objective, like blood pressure, or subjective, like feeling more energy? After the claim is clarified the next step is to search for ALL the evidence surrounding this claim. The evidence that can prove the claim AND the evidence that can disprove the claim. This step is critical. The feature which most distinguishes good science from pseudoscience is that good science tries to disconfirm its claims whereas pseudoscience only tries to confirm its claims. Finally, the evidence needs to be ranked by quality. We have learned through the history of medicine that there is a hierarchy of evidence. Some evidence is more reliable than others. Randomized controlled trials yield more reliable evidence than anecdotal evidence, laboratory evidence, observational evidence, authority, and ancient wisdom.
Critical thinking also involves spotting red flags such as: implausible mechanisms, conflicts of interest, conspiracy theory, cherry-picking, and references that lead to nowhere. For a full demonstration of critical thinking in medicine, please see my post regarding 'Opposing nutritional claims' or my lecture on 'How to evaluate supplements'.
Although Integrative Medicine doctors also employ a comprehensive approach to provide their patients with all the options, the subsequent critical thinking and ranking of the evidence is conspicuously absent. This is because Integrative Medicine is defined by its acceptance of all forms of evidence. Anecdotal evidence, laboratory evidence, observational evidence, authority, and ancient wisdom are all acceptable forms of evidence. In fact, so many of its treatments are based on implausible ideas and weak forms of evidence that any attempt at a hierarchy of evidence would result in an implosion of the field. Instead, claims are taken at face value without comparison with competing claims. There is no criticism or peer review. Everything works and everything works equally.
Shared Decision Making
There are many decisions in medicine that are straightforward and do not require much deliberation. For instance, an open hip fracture must be treated with surgery, a persistent blood pressure of 240/120 should be treated with medications. However, there are many decisions that are not so straightforward. The evidence is conflicting, the evidence is lacking, or the treatment has almost as many risks as benefits. Examples include: prostate cancer screening with PSA, intermittent fasting, genetic testing, testosterone replacement, chemotherapy for metastatic pancreatic cancer. This is where shared decision making comes in.
The first component of shared decision making is to identify which decisions are straightforward and which decisions are difficult. This crucial step requires a doctor with: a comprehensive knowledge base of options, an analytic approach to decide which options are likely to work and which are not, and a doctor free from bias. Once a difficult decision is identified, the doctor must synthesize the information and present it so you can understand the risks and benefits in plain english. Finally, your values and preferences are integrated into the decision making process. For instance, do you value quality of life more than quantity of life? Would you like to know you have a disease that has no treatment? Would you accept a treatment even if it does not perform better than placebo? Incorporating these core values into your decision ensures you make the medical decision best suited for you. (For more information on shared decision making see the Mayo Clinic website.)
Autonomy is the right to make medical decisions for yourself. It is considered the most important ethical concept in contemporary medicine. The essential ingredient of autonomy is good information. Only with good information, can you make good decisions for yourself. However, in healthcare there is an asymmetry of information. The doctor knows more than the patient. This leaves the patient vulnerable and at the whim of the doctor. In terms of healthcare economics, the supplier of healthcare (the doctor) is left to dictate what is necessary and what is not; thus, the supplier is creating the demand - supplier induced demand. It is therefore an imperative that you get accurate information. You must ask questions and get the right answers.
Allow me to provide a poignant example. A cardiac stent to open a blocked artery can save your life when deployed at the beginning of a heart attack. When the blockage is chronic however, a stent is of no benefit. A survey of Cardiologists and their patients was conducted just prior to the placement of a stent for chronic blockage. The majority of the Cardiologists acknowledged stents would not prolong life or prevent heart attacks. Conversely, eighty percent of the patients believed stents would prolong life and prevent heart attacks.This represented an alarming disparity between the perception of patients and the truth. Either the patients did not ask questions, did not ask the right questions, or were given false answers. They had their autonomy stripped because of bad information. They may have avoided the procedure if they had good information.
Getting good information, not only applies to doctors, but to any source of medical information including the internet or social media. We are living in an exciting information age with freedom of expression and an explosion of ideas. Yet, these freedoms come at a cost; it has become increasingly difficult to tell good information from bad. Consequently, it is more important than ever to have a trusted source of medical information; a trusted healthcare professional to bounce things off.
My practice is designed to give you good information or to give you the tools to find it for yourself. First, I try to level the information playing field between you and your doctors. While most primary care doctors spend only twenty percent of a visit on patient education, in my practice this is reversed. I spend the majority of our time together on education. Second, I aim to make information unbiased, accurate, and complete. And finally, I foster an environment of questioning, critical thinking and openness. You and I will peer review the recommendations of others and make them accountable - no one is above questioning. Only with good information are you empowered to make good decisions for yourself.