Academic Medicine and Concierge Practice
Academic Medicine and Concierge Practice
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DOI：
10.7326/l16-0103
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发表时间：
2016-09
影响因子：
39.2
通讯作者：
M. Donohoe
中科院分区：
文献类型：
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作者：
M. Donohoe
致编辑：Doherty (1) 没有提及许多豪华护理诊所是由学术医疗中心赞助的。有些与国家礼宾护理公司合作。此类诊所的营销目标是成功的小型和大型公司的负责人，其中白人男性比例过高。许多豪华护理诊所的医生只向富人提供服务 (2, 3)。与其他类型诊所的医生相比，保留诊所的医生照顾的非裔美国人、西班牙裔和医疗补助患者较少；此外，转为保留执业的医生平均只保留了 12% 的以前的患者，从而给社区中其他已经超负荷工作的医生带来了负担 (4)。公众通过州和联邦税收为新医生的教育和培训做出了巨大贡献，因此可能很难接受医生将其执业范围仅限于富人（5）。尽管学术医疗中心作为穷人和服务不足的传统提供者，可能会通过功利主义理由证明赞助豪华诊所是合理的，但只有两个项目利用这些企业的收入来交叉补贴对贫困人口的护理或教学项目。没有高质量的证据证明礼宾服务的护理质量更高，也很少有数据支持向无症状客户提供的许多不必要的检测的临床或成本效益 (2, 3)。过度检测可能会导致假阳性结果，从而导致进一步不必要的调查、额外费用和加剧的焦虑。真阳性结果可能会导致对临床上不重要的疾病进行过度诊断，从而导致进一步的危险干预措施，并可能损害未来的可保性。使用临床上不合理的测试会侵蚀医疗实践的科学基础，违背医生负责任地管理有限医疗保健资源的道德义务，并可能导致更糟糕的护理。大多数职业道德培训以及循证实践指南的制定和教学都是在医学院和教学医院进行的。没有关于医学生和住院医生参与教学医院豪华护理诊所的数据。对于这样的机构来说，教导学生平等对待所有患者，消除医疗保健获取和结果方面的不平等，并实践循证医学，同时支持相反的诊所，这是令人不安的。至少，实习生不应该被允许在这样的诊所工作。
TO THE EDITOR: Doherty (1) neglects to mention that many luxury care clinics are sponsored by academic medical centers. Some partner with national concierge care companies. Marketing for such clinics is directed at the heads of successful small and large companies, who are disproportionately white men. Many physicians who staff luxury care clinics limit their practices to the wealthy (2, 3). Physicians in retainer practices care for fewer African Americans, Hispanics, and Medicaid patients than those in other types of practices; moreover, physicians who switch to a retainer practice keep an average of only 12% of their former patients, thus burdening other, already overworked physicians in the community (4). The general public contributes substantially to the education and training of new physicians through state and federal taxes and thus might find it hard to accept physicians limiting their practices to wealthy persons (5). Although academic medical centers, traditional providers for the poor and underserved, might justify sponsoring luxury clinics via a utilitarian argument, only 2 programs use income from these ventures to cross-subsidize care for indigent persons or teaching programs. There is no high-quality evidence documenting a higher caliber of care in concierge practices, and few data support the clinical or cost-effectiveness of many of the unnecessary tests offered to asymptomatic clients (2, 3). Overtesting may result in false-positive results, leading to further unnecessary investigations, additional costs, and heightened anxiety. True-positive results may lead to overdiagnosis of conditions that would not have become clinically significant, leading to further risky interventions and possibly impairing future insurability. The use of clinically unjustifiable tests erodes the scientific underpinnings of medical practice, runs counter to the ethical obligations of physicians to responsibly manage limited health care resources, and likely leads to worse care. Most training in professional ethics, as well as the development and teaching of evidence-based practice guidelines, takes place in medical schools and teaching hospitals. No data are available on the participation of medical students and residents in luxury care clinics at teaching hospitals. For such institutions to teach students to treat all patients equally, combat inequalities in health care access and outcomes, and practice evidence-based medicine while at the same time supporting clinics that do the antithesis is troubling. At the least, trainees should not be allowed to work in such clinics.