Bad Medicine

An interesting discussion between DB and My Med Body on the ethics of retainer medicine — a model of primary care medicine where patients (generally an affluent subset) pay out of pocket for a physician to attend to them. Because each patient pays more for their care, the physician has a lighter load, more time available for examination, can make house calls, etc. Generally rates high for both physician and patient satisfaction, in an era in which maintaining a primary care practice is becoming increasingly difficult.

The argument, as I see it, runs thusly: Med Body points out a (weak) ethical obligation on physicians to provide health care to people who need it most (and of course, implied that that population is the poor and underserved who are going to be left out of any self-pay practice), and thus that retainer medicine is by its very nature racist and classist. He also notes that retainer medicine is untenable as a general model for primary care, since there aren’t enough doctors to provide that level of personalized care for everyone.

DB responds that retainer medicine isn’t any different than specialty medicine or administration, where serving the neediest (in this usage, a slightly different definition in play) takes a back seat to a nice pay check and generally higher job satisfaction. He also cedes that retainer medicine is untenable, but that the true comparison isn’t with nothing (or an ideal single payer system), but with the present one, where primary care docs (especially those who try to strike out on their own) are finding it increasingly difficult to make ends meet while still providing a level of care they find conscionable. And leaving outpatient primary care for hospital medicine and subspecialist positions at an alarming rate).

Myself (and thanks for asking!) I tend to agree with Med Body about the ethical obligation to provide care to the neediest, although my definition of both care and need are somewhat idiosyncratic (I subscribe to the rather uncontroversial view that we should give useful treatments to people who will benefit from them first, but I have got only a very foggy idea of what that means in terms of interventions and populations, and suspect it’s somewhat more limited than I’ve previously imagined). Constrained in large part by pragmatic concerns, I think that ethical obligation is very weak indeed. So weak, in fact, that I would have a hard time faulting anyone for violating it (which, for the record, I agree with DB that many subspecialists do).

So, I think that a far more productive discussion than whether an individual doctor is acting (un)ethically by becoming a retainer physician is one that would attempt to answer the following questions: