Not too long ago, a friend of mine in Philadelphia asked for a suggestion for a primary care provider (PCP). I referred him and his wife to our PCP, my wife and I having been that doctor’s patients for 18 years. We rarely see our doctor, truth be told, but he’s a Hopkins graduate, a good internist, and always returns calls personally and promptly.

My friend subsequently e-mailed me to ask for another suggestion, as our PCP has apparently switched to a “boutique” practice and there’s no way they could afford the annual membership fee. Such fees usually range from $1,000 – $3,000 each year. You’d think he was joining a country club or something Our doctor’s switch to a boutique practice was news to me, but as we rarely see our PCP, it’s not surprising we weren’t notified. Our strategy was going to be to hold out and hope our PCP would switch back to a non-exclusive practice, once he realized that this new approach was not popular and he was losing money.

Wishful thinking.

I had to call my PCP today for a referral and as usual, he returned my call personally and within a short period of time. I was asked by his answering service, however, if I was a “VIP” patient. I said we’ve been his patients for 18 years. I mean, that should count for something, right? So I spoke with our doctor about his new boutique practice. He told me that tons of people are signing up, and those who don’t can always see his partner as she still takes insurance. Boutique practices by definition are fee-for-service, cash-only. So in order to continue seeing our PCP of 18 years, we have to pony up a large annual membership fee. Thus, like my friend in Philadelphia, we’re looking for a new PCP.

I can’t blame our soon-to-be former PCP, really. Given that the average physician pays almost $70,000/year to argue with insurance companies it makes little sense any more to participate with third-party payors. This guy is a good doctor and he’s now able to continue doing what he had been doing all along and what he likes to do: practice good medicine in a personalized fashion.

Just like I understand why many of my gynecology colleagues have taken up cosmetic surgery, I understand the allure of boutique medicine. But both of these trends offend my sensabilities and epitomize a medical system gone astray. Boutique medicine establishes another tier in our multitiered health care system. If you have money, youre fine. If not, good luck.

And while I don’t expect all physicians to practice the way I used to practice, I do expect some basic tenets to hold. I returned patient calls. I saw them personally. I didn’t charge extra for what I viewed as quality standard medical practice. Who would have thought I should charge to see a patient in a timely fashion or return their calls myself or write a disability letter? I just stupidly thought this is what one does as a doctor.

So medicine has changed. And not really for the better. If you want to have personalized care like many of us used to provide as a matter of course, you have to pay extra for it. If you’re a surgical gynecologist, you might want to supplement your decreasing revenues from managed care by providing cosmetic services. And so on and so forth.

It’s crazy. Every time I get a hankering to go back to practicing gynecologic surgery, stuff like this gives me the kick in the ass reality check I need to contnue doing the fun stuff I’m doing. But it’s still a shame to see what’s happened to medicine.