Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Retail Medicine

I just returned from a challenging shopping experience at Costco. With your indulgence, I’ll set the scene as follows — It’s been a hard weekend with two sick children, the six year-old just getting over a week-long sinus infection, and the four month-old with her first severe illness. My wife and I have spent the last two nights sleeplessly, with the baby sneezing, gagging, vomiting, and generally miserable with almost equally miserable, worrying parents. To top it off, we had completely run out of food. Hence my ill-fated Sunday trip to Costco in which I could have been in a much better mood. My intrepid shopping experience had me thinking about the changing tides within the medical community and the worries about the future of the solo practice.

I’m sure the vast majority of readers are familiar with Costco, but for those who are not, I’ll quickly explain. Costco is a huge membership-based warehouse-style store in which you buy bulk items for a discount. This is in contradistinction to the old-style “mom and pop” store that I remember from my childhood, called King Kullen, in which service was more personalized, but a little more expensive. Perhaps the modern day big box grocery experience might be Trader Joes, where you can purchase a variety of organic produce and artisanal foods, in a neighborhood-like environment with artistic chalkboard drawings, friendly staff, and old-fashioned paper bags.

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Now, let’s take these two stores as an analogy for today’s medical practice. Large health organizations like Kaiser Permanente or the Veteran’s Affairs medical system are comparable to Costco with its corporate structure, high volume capacity, and convenient multi-specialty access. Compare this to the solo medical practice in which – optimally at least – the doctor-patient relationship may be more personal. The prime example of this may be the concierge practice, in which patients pay a retainer fee to their physician, for better customer service. Care here takes place in a boutique-style high service environment. I will say that my analogy does break down in the fact that many physicians at large healthcare systems do take the time to get to know their patients and provide outstanding care, while the opposite is true for some private practitioners. But you get my point.

For some patients, the larger, more convenient, 'big box' medical service is preferable.
For other patients the boutique-style service of the private practice may be preferred.
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For some patients, the larger, more convenient, “big box” medical service is preferable. When I was a student, I had Kaiser Permanente insurance (Northern California). I found some aspects of Kaiser to be disconcerting. For example, being moved about a facility like cattle, or having the suspicious feeling at the pharmacy that I might have accidentally turned into a McDonald’s store was a check in the negative category. For all intents and purposes, I was a number. However, during a particular visit, my wife was seeing her primary care provider (a kind, friendly, and engaging doctor) regarding a dermatologic lesion. The PCP wasn’t sure about the diagnosis, so she called in a dermatologist who actually walked over from his office and did a quick “curb-side” consultation! Imagine our surprise at this excellent level of coordinated care.

For other patients the boutique-style service of the private practice may be preferred. This Cheers version of medicine, in which “everybody knows your name,” has the benefit of perceived personalization. The doctor can spend as much time with the patient as he or she desires, since s/he owns the practice, providing a level of customer service that may outshine the larger health systems.

Regardless of which version of medicine you prefer or provide, the question of what the future holds remains unanswered and is quite concerning. Pretend for a moment that you’re the Costco version of medicine. A large payer with a huge number of potential customers – Medicare – now requires ever more stringent adherence to rules (for example EMR “meaningful use”). As Costco Health Care, you are large, with deep pockets, and have a corporate structure that is capable of adjusting to the cost and changes.

The smaller scale practice, lacking the corporate structure and resources, stands to disappear.

Now take the King Kullen Medical practice (or any of a large number of solo practitioners today). Apply these same rules and large scale medical changes - such as a 27% Medicare reimbursement reduction – and you have a completely different potential result. The smaller scale practice, lacking the corporate structure and resources, stands to disappear.

Where the medical system ends up – as either Costco, King Kullen, or somewhere in between – is anyone’s guess. Regardless, I think it’ll be a sad day if the sole practitioner model disappears. I keep thinking of the movie You’ve Got Mail in which Meg Ryan’s neighborhood book store, Shop Around the Corner, is eliminated by Tom Hank’s mega-store Fox Books. Unfortunately, we’re not all living in a Nora Ephron story in which these two competing interests magically end up living happily ever after. I see a different end in sight.
How did my shopping experience at Costco end you might ask? I got into an argument with two nameless checkout people because I failed to pick up the second of the “two for the price of one” bagels.

“You can’t leave without the second bag of bagels,” nameless person one said.

“What are you going to do, tackle me if I leave?” I argued (bad mood turning to sarcasm).

“No, but my audit won’t come out right,” he said.

God forbid his audit comes out wrong.