Recently, I read about two New York City physicians who have started a concierge primary care practice where patients “come for the stress test and stay for the collagen.”1 Although some features of the practice seemed laudable — being more available to patients — others struck a nerve. The physicians plan to take “a comprehensive, methodical approach to life extension,” and one founding physician “envisions administering state-of-the-art screenings that use biochemical markers to identify potential predictors of cancer.” It all sounded fishy to me, so I posted the article on Facebook, with a single word: “Shameful.”
By the end of the day, there were critics. A fellow physician demanded to know, “Why is this shameful?” He argued that people should be free to pay for whatever they want as long as it does not affect the rest of us. I rallied, arguing that when unnecessary testing detects abnormalities, the downstream tests and procedures are often covered by insurance, which does affect the rest of us. Others came to my defence. There is no cure for aging, a colleague argued, and boutique practices that promote unproven remedies undermine the public’s trust in physicians. Yet another doctor drew analogies to the personalized care Michael Jackson received, and a physician friend noted that not being able to see why this is shameful is itself shameful. Several others showered “likes” on some, any or all of these comments, and I couldn’t help but see this as the future of community discourse.
Shame: dishonour; the awareness of guilt or inadequacy. My word choice was impulsive and unreflective, but with the advantage of retrospect, I had to wonder, was it right? What exactly was shameful? There were the facts of course. Although concierge practices are increasingly common in the United States, they are growing internationally, and a report by CTV News catalogues the controversial rise of concierge practices in Canada.2 Concierge medicine captures the tension between a laudable desire for primary care doctors to be more available to patients and concern that the very nature of such practices subverts the essential egalitarianism of medicine: the principle that patients are entitled to the best care possible regardless of wealth.3 But my response was also visceral.
I tried to untangle the emotion. First, there was the article itself. It stuck in my craw. Toward the end it states: “The risk of course is … the development of a two- (or really three-) tiered medical system … in which only the best-off remain, living the longest and healthiest lives, never looking a day older than Mary-Kate Olsen, and moving into luxury condominiums built with CT scanners.” What the hell were they talking about? It was simply a false narrative.
The truth about good primary care medicine is that it gets better only to a point, beyond which money does not buy better care. If you follow recommendations for age-appropriate, evidence-based screenings, eat well and exercise, then more tests only mean more follow-up scans, more incidental findings and more misspent money and time.
Second, there’s the very idea of life extension. It sounded pompous and futuristic. Living a long and happy life makes you think of an uplifting drama. Life extension makes you think of a sci-fi hellscape where meals come in pill form.
Third, there was the article’s quote about stress tests and collagen injections. The two were just bandied about, as if both are casual, esthetic choices: coronary artery bypass surgery and a tummy tuck; combination chemotherapy and botox; home hospice and a facelift. These are not concordant things.
“Why is this shameful?” the critic asks. I imagine the conversation we never had. I make my case. The critic grows irritated. He has heard this sort of thing before.
“So what? What do you want them to do? They have to eat.”
“Sure, they have to eat. But caviar? At every meal?”
“What do you want to do? Ban concierge practices? Make some more rules? What about personal freedom?”
“Whoa. Who said anything about banning? I just want to be on the record as saying this is shameful.”
“What record?’
“The Facebook record?”
“No one cares what you think, and maybe it’s shameful to judge.”
“Maybe you’re right. But, can we at least agree that something here is shameful?”
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