Salt Lake City internist Beth Hanlon joined a growing number of doctors embracing “concierge” health care. She closed her traditional practice and reopened at the same location under the banner of a concierge company, MDVIP. Patients pay her an $1,500 annual membership fee on top of their regular insurance costs, in exchange for more personalized care and round-the-clock access.
Hanlon yearned for a return to the ”Marcus Welby” style of doctoring practiced years ago by her father, who carried a weathered black bag and made house calls — ”the quintessential internist, always there when you need him, or her,” says Hanlon.
How has her new practice fared? Following are excerpts from a journal she kept during 2012.
Weeks into informing our patients about this new model finds us more and more solidified in our decision. We had to say goodbye to some long-term patients. But we find ourselves telling friends and patients about the new practice at places like the grocery store, theater and the mall. Their enthusiasm is contagious.
I saw an octogenarian widow today, a routine visit to check her blood pressure. Though I was about 30 minutes late for my next patient, I sensed her need to say more. She confessed the holidays were going to be lonely. We spent 10 to 15 minutes talking about families, relationships and what we do when we are lonely. When she left, we both had a bit more of the holiday spirit. I bet her blood pressure was lower, too! Our visit gave me insight to what patients and I have to look forward to.
I am seeing a full schedule of patients, typically 20 or more a day. In my new practice, I will be seeing maybe 10, a big change.
My first day of my new practice, I was both excited, and filled with expectations that something would seem so different. My excitement spread to the staff; someone brought balloons and flowers. But mostly, the day was another day of meeting with patients, though fewer, and doing what I do, day after day.
I saw a lady I have known for years. Her blood pressure was running high, despite increased doses of her medication. We discussed diet and I asked about over-the-counter meds. She remembered to tell me she takes herbs, some of which — including bacopa and ashwagandha — were new to me. I told her I would have to check them out. Within a couple of hours I confirmed that one or two might interfere with her medications. In my traditional practice, it might have taken me a few days or up to a week to find the time to research those herbs.
Yesterday, a daughter brought in her dad who is getting older (aren't we all). She does so much for him, laying out his meds once a week and getting friends to give him a ride to the senior center, coffee shop or grocery store. He is a widower, and doesn't do much house cleaning so she does his laundry and prepares meals. He is adamant about not leaving his house. But she works full-time and can't always be there for him. She wants him to come live with her, or move to a facility with more oversight.
After listening and gaining insight into his past, his relationship with his daughter and his living situation, I was able to find a middle ground. I directed them to resources that may help, including private care and meal delivery services. We reduced, and changed the timing of some of his medications, to simplify the regimen. By the time they left, we had a plan. All agreed, including dad, that we would meet back to review, and if necessary make changes. Without the extra time, I might have written orders to have this man placed in a living facility or nursing home, perhaps making the situation untenable for the whole family.
An elderly lady phoned saying that for the past few days she's been dizzy and short of breath. I had her come right into the office. She had a rapid heartbeat and her blood pressure and oxygen were low, so I admitted her to the hospital for observation. Her visit was shorter and more productive because I had the time to talk with the admitting doctor, send my records to him and call a cardiologist before she got there. Had her family called last month, I would have probably sent her to the ER where she might have waited for hours to be hospitalized for days without my ever knowing it.
A month into my new practice and I unquestionably see benefits for my patients. They are relaxed in the exam room and our discussions include a great deal more detail. While updating the chart of a 54-year-old patient of mine, I discovered she has three family members with pancreatic cancer, two with ovarian cancer and one with breast cancer. Previously, my family history for this patient had simply said, "lots of cancer." With some research I found there might be a genetic syndrome for which this family can be tested.
And the patient with the dangerous herbs? She returned today for a check-up. Her blood pressure was normal and she said she didn't miss the supplements. She couldn't remember why she took them anyway.
Last autumn, my son was overheard telling a friend's mom how hard I work, and how he doesn't see me much. He explained that he was afraid this change in my practice would mean I will be on the phone all the time, and might not be home very often for family game night. He is 16. Last week, he told me he is glad we have had more family game nights together and said I seem less stressed.
And he is right. I am spending the same amount of time at the office, but my evenings are more family-oriented, because I'm not preoccupied with research and phone calls that I wasn't able to get to during the day.
One man, new to my practice, has multiple medical problems, including diabetes and some mild cognitive impairment. It takes extra time to review and explain his medications, and he is easily overwhelmed. So we communicate weekly. He emails me each week with his glucose readings and I email him what dose of insulin to take. I see him in person monthly and test his blood sugar levels. After only two months of this tailored care, his levels have significantly improved. He's less depressed because he feels more confident. In a traditional model of practice it would be difficult to deliver this personalized approach.
We see the adolescent children of some of our patients as a courtesy. Last week, a daughter of one of my patients came in for a rash that was spreading across her trunk, which she feared was some contagious disease. Her mom has anxiety, and while the daughter had never had this diagnosed, it was evident she suffered some of the same idiosyncrasies. The rash was not contagious, but I thought it might be worse because of her anxiety. She needed to quit scratching, use a salve I prescribed, and start exercising as a release. When I called today to see how she was doing, her mom told me she was better, and that the two of them were now walking together as a stress outlet.
There is no greater thrill than setting health improvement goals with patients and witnessing their excitement as they achieve those objectives. Today I saw a patient who, on the opening week of my practice, set some exercise and weight-loss goals to better control her blood pressure. In six weeks she has lost 20 pounds; her goal was only 10. Back in December I suggested a lower calorie diet and minimalist exercise regimen. She had been very sedentary, and her diet had been one of daily fast food. She is making her own meals twice a day now, still has one "fast food " meal a day, but makes a much healthier choice. I follow her progress on our web portal tracker, and while she doesn't file daily updates I get a flavor for what changes might improve her outcome. She loves getting a weekly email from me, and feels that is motivation to keep going.
An unexpected pleasure as a result of the change in my practice is the genuine interest patients are showing in me personally. At the conclusion of many visits, they will inquire after my children and what those three Hanlon kids are up to now, or they express concern about the health of my father.
My father has recently been diagnosed with metastatic stomach cancer. As I offer him emotional support and help him navigate the maze of his health care, I am more appreciative of what my patients are experiencing.
While screening for diseases remains controversial, it has positively impacted my practice. The controversy of screening is that there may be false positives leading to additional, and perhaps, unnecessary testing.
But this month I have seen how disease screening can give patients the “wake up call” that they need to change bad health habits. One of the tests we offer all patients is a pulmonary spirometry. This month we screened a 50-year-old nonsmoker with no lung problems, and her results were abnormal. I ordered a few additional tests, and started her on inhalers like the ones asthma patients use. She returned this week and is happy to report her exercise tolerance has improved! Now she can compete in the Salt Lake Marathon – something on her "bucket list."
MDVIP's payment model allows us more freedom to treat patients remotely and put technology to better use. A patient called two weeks ago about a wound on her foot. She was leaving town and wanted to make sure it wasn't too serious. I had her take a picture with her iPhone and send it to my email. It wasn't the best quality, but I could tell it looked like athlete's foot. So I suggested an over-the-counter cream twice a day, and she was off on her trip.
A real pleasure I am finding in this practice is learning the personal details of my patients. One guy tinkers with old Model-T Fords, and another plays bagpipes. I've been to patients' art shows and book signings. When my patients take trips, I get postcards (recently from Kentucky, Paris and Germany). I am enjoying the trips as much as they are!
It's been a few months since I wrote in my journal. My Dad passed away about five weeks ago. I spent at least one weekend with him each month before he died, traveling to Iowa to see him. In his final months, he and I had a lot of conversations about dying, comfort, and medications that did nothing to help, his fears, frustrations, his desire to make the best of every day. What I share with my terminal patients is so much more meaningful now.
I have been making several house calls this month. My nurse and I now coordinate home care for elderly patients who live relatively close. The home visits give me more insight into their needs. For those that live in Assisted Living Centers, it becomes evident how long a hall is to the dining room and whether the "work out" facilities are usable. I see patients' medications piled up on top of the microwave in a confusing disarray, I see the notes I have written with instructions on the refrigerator and understand how they can be confusing. It takes more time, but the rewards are profound.
I have an elderly patient on hospice, at home with his wife, his primary caretaker. She is frightened, unsure, and not very confident about her care-giving skills. I have made a few house calls, showed her some "nurturing" skills I learned, while helping my mom care for my dad. I guide this anxious lady to do the little things like rubbing his feet, washing his hair, filing his nails and reading or singing to him. I told her not to stress about meals and what he isn't eating. When I suggested a sponge bath, she asked, "How do I do that?" I had never done one myself, so I asked my mother, a nurse, who had lots of practice. I know the caregiver could have called the hospice nurse but she called me. What a privilege.
Medication prices are soaring. Patients all over the country are splitting pills, skipping pills, or worse, not filling prescriptions. A couple in their seventies recently joined my practice because they hoped I could review their medications. They do not have prescription insurance coverage and they wanted me to help them decide if there were cheaper options. One of them had been "fired" by their prior physician for lack of compliance in taking medications he had prescribed. She didn't take them because she could not afford them, and was too embarrassed to tell the doctor that. While this is not typical of most physicians, it underscores the frustration in taking care of patients who don't do as recommended. In this case, had the couple and the doctor had more time to review concerns together, their relationship would not have ended this way. This particular patient was able to control her blood pressure with a couple of generic medications that cost less than the one previously prescribed and sampled.
I have deeper relationships with patients now, so we share our sorrows and joys. Today, a patient asked about my dad and his illness. She knew how close I had been to my dad, and I told her how much I miss him, and that I still say in my head "gotta tell dad about this." Her kindness moved me to tears as we talked and she listened to me express how peaceful Dad's death was, with all of us there with him — my mom and my six siblings. This new element in my practice was a bit unforeseen, but I relish it. This patient and I both know our relationship is deeper now. And as we discussed that fact, she confessed this personal approach was helping to motivate her to achieve her health goals.