DC Medical Malpractice & Patient Safety Blog

Despite the overwhelming evidence in favor of childhood vaccinations, there’s been a lot of buzz lately about their safety and scheduling. Lost in all that chatter is the fact that the rate for adult vaccinations is lower than that for children, and, according to the Centers for Disease Control and Prevention (CDC), unacceptably low.

We're talking about more than just flu shots here.

The CDC reported last month that although more people were getting the Tdap vaccine, which protects against tetanus, diphtheria and pertussis or whooping cough, adults are not getting vaccinated against other illnesses, such as pneumonia and hepatitis.

"While everyone knows about the importance of the flu vaccine and childhood vaccination, adults are unaware" about other diseases they need to protect themselves against, including whooping cough and shingles, said Assistant Secretary of Health and Human Services Dr. Howard Koh during a media session with reporters including those from MedPage Today.com.

For example, only about 12 in 100 adults between 19 and 49 have been vaccinated against hepatitis A; about 36 in 100 adults the same ages have been vaccinated against hepatitis B. Target rates are 9 in 10 for both.

Both hepatitis A and B damage the liver, and are caused by a virus. (Hepatitis C also affects the liver, but there is no vaccine.) You get the A virus from: eating or drinking contaminated food or water; coming into contact with the stool or blood of a person with the disease; participating in certain sexual practices with someone with the disease. You get the B virus from: having a blood transfusion (rare in the U.S.); coming into direct contact with blood in health-care settings; sexual contact with an infected person; tattoos or acupuncture with unclean needles or instruments; sharing needles during drug use; sharing personal items (toothbrushes, razors, nail clippers) with an infected person. You can also get the B virus at birth if your mother had hepatitis B. This is common in some Asian countries.

Vaccination rates for all illnesses rise after an outbreak, when people are more aware of the diseases and their consequences, but you don’t get the most protection unless you’re vaccinated before being exposed.

The CDC analyzed coverage rates for six shots. (I discussed shingles, the common name for herpes zoster, in my newsletter here.) They are:

• Pneumococcal disease


• Tdap


• Hepatitis A


• Hepatitis B


• Herpes zoster


• HPV (human papillomavirus)

HPV is effective only if you get it before you’re sexually active; it’s recommended that the first shot in the series be given to children in the early middle-school years.

One CDC official called coverage rates for the pneumococcal vaccine "way too low"; only 1 in 5 high-risk adults 19 to 65,and only 6 in 10 adults 65 and older were vaccinated. The CDC's Healthy People 2020 initiative sets a goal of 9 in 10 older people, and 6 in 10 for the high-risk population.

Only about 16 in 100 people 60 and older are getting the herpes zoster vaccine; the goal is 30 in 100.

Cost, for once, should not be an issue for most people—the Affordable Care Act (Obama’s health-care reform) makes preventive services, which includes vaccines, free to all insured patients.

Different people need different vaccines. According to the CDC, some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives. Generally this is true, except that:

• Some adults were never vaccinated as children.


• Newer vaccines were not available when some adults were children.


• Immunity can begin to fade over time.


• As we age, we become more susceptible to serious disease caused by common infections (such as flu and pneumococcus; shingles can strike anyone who ever had chicken pox).

If you haven’t been vaccinated lately, or can’t remember the last time you got a vaccination, contact your doctor to review your medical record. Schedule an appointment if you’re due for a vaccination, or contact a drugstore-affiliated clinic to see what vaccines they have—many can accommodate you on a walk-in basis.

To find out what vaccines are recommended for what groups of adults (by age and/or risk factor, link to the CDC’s Immunization Schedule.

The New York Times’ venerable health columnist Jane Brody recently wrote about the advisability of the annual physical checkup. It’s a topic we’ve covered, too, reaching mostly the same conclusion: In most cases, an annual doctor examination is a poor use of time, money and medical resources.

As Brody points out, trying to figure out if a routine checkup is a good idea is more important than ever, because next year, the Affordable Care Act (“Obamacare”) will enable about 30 million more people to be insured. Many of them will be eligible for an annual exam that insurance plans must cover. That’s a lot of potential demand on a resource stretched pretty thin.

So who should get a checkup? And how often?

According to one of Brody’s sources, about 44.4 million adults get preventive exams every year. If every U.S. adult got one, 145 million more visits would occur every year, and gobble up almost half of all the time primary care doctors spend with patients. And you think the health-care system is slow, inefficient and frustrating now?

No one within or outside of the medical community disputes the wisdom of regular checkups for babies, children and pregnant women. No one disputes the wisdom of exams that include specific screenings for certain populations, such as Pap smears for women. But, as Brody says, “Among physicians, researchers and insurers, there is an ongoing debate as to whether regular checkups really reduce the chances of becoming seriously ill or dying of an illness that would have been treatable had it been detected sooner.”

Those who vote “no” point to a growing number of studies that fail to find a benefit that outweighs the risk that they’ll do more harm by finding something abnormal that, if it had never been discovered, would never have done harm. Something can be technically "abnormal" without being threatening or even, sometimes, interesting.

But the default behavior by too many practitioners is to conduct extra tests. This causes the patient distress, expense and, sometimes, medical complication.

One of Brody’s examples was provided by a physician who told the tale of Brian Mulroney, former prime minister of Canada. He had a physical in 2005 that included a CT scan. It showed two small lumps in his lungs. He underwent surgery to find out what they were, after which he developed an inflamed pancreas that forced him into the intensive care unit. He was in the hospital six weeks, and readmitted a month later to remove a cyst caused by the inflammation of his pancreas.

Oh, and the lung lumps were benign.

Of course, the question arises: What if the lumps had been cancerous? Wouldn’t the initial scan and all the unpleasant consequences of it have been worth it in order to be able to treat the cancer?

“The question of benefits versus risks from routine exams,” Brody writes, “can be answered only by well-designed scientific research.”

One recent study cited in her story was conducted at the Nordic Cochrane Center in Copenhagen, Denmark.

Researchers analyzed 14 clinical trials of routine checkups that followed participants for as long as 22 years. The team found that healthy people who got routine checkups got no benefit in terms of the risk of death or serious illness compared with compared with people who did not.

And as we’ve said in this blog repeatedly, the researchers concluded that many routine exams involve specific screening tests whose value hasn’t been studied adequately. The possible harms of such routine tests, they said, are “overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results [a test that shows the existence of a potential problem when there isn’t one], false reassurance due to false negative test results [tests that don’t show a problem when there is one], adverse psychosocial effects due to labeling and difficulties with getting insurance.”

Among a general population—that is, the subjects weren’t chosen because they did or didn’t have certain risk factors of medical problems—the Danish team simply didn’t find that having a checkup reduced the possibility of dying any more than not having one. Nor did they find any reduction in cardiovascular problems and cancer—the causes of death most likely to be influenced by health checkups.

But a regular doctor appointment can be useful, Brody says, noting that many doctors welcome an annual visit even when their patients don’t have a medical issue because it’s good for the relationship—it helps alert them to changes in patients’ lives that can affect health. And doctors can use that time to encourage patients to get needed immunizations and other health care, such as eye and dental exams that have proven benefits with almost no risk.

So what’s a person to do if she wants to monitor her health without overdoing it?

Brody has three pieces of advice:

1. Whenever you visit the doctor for any reason, have your blood pressure checked and get blood tests if the ones in your medical record are older than a year.

2. Remain current on immunizations—flu shots, tetanus, shingles, etc. (If you don’t know which vaccinations you should have, ask. Some are recommended for certain age groups or if you have certain risk factors.) Get the screening tests specifically recommended for your profile—age, gender, risk factors, family and personal medical history.

3. Some symptoms require attention. If you develop unexplained pain, shortness of breath, digestive problems, a lump, a skin lesion that doesn’t heal, or unusual fatigue or depression, call your doctor. If the problem is diagnosed and treated, ask when you should feel relief. If that time has come, and you’re not feeling better, seek further help.

See our newsletter on vaccine shots worth getting, and other screening tests that are a smart idea.

Gerontology is the study of health issues that go with old age and aging. It’s a medical specialty because, like the very young, older people have different biological, psychological and sociological needs. Medicare, the health insurance program that covers people in the U.S. starting at age 65, addresses many of the financial concerns of this population, but what about the hands-on care?

In a blog posted on KevinMd.com, Dr. Steven Reznick, an internal medicine physician, writes about his elderly parents residing in an assisted living facility. They are cognitively impaired, so he’s in contact with their personal physician, and lives nearby. They are lucky.

What if the circumstances were different? “What,” he asked, “would I look for in a physician for my elderly parents if they did not live close by?” Here’s his advice to older patients and their loved ones for choosing the right doctor.

• Find someone with experience in geriatric medicine. Such practitioners have training and certification from the American Geriatrics Society. A board-certified internist or family practitioner with experience in caring for the elderly also might be fine. Either specialist should be available by phone for questions and to see patients on the same day that they develop a problem requiring a doctor’s attention.


• The doctor should have hospital privileges at a local facility where patients might be taken by ambulance in an emergency. You want someone who can follow the patient into an acute care hospital if necessary. He or she also should have a professional relationship with a rehabilitation or skilled nursing facility so that patients can be treated in a rehab facility as they recover from an acute hospital stay.


• The doctor should be a compassionate individual; a great listener and energetic advocate for his or her patients. It’s all too common for elderly patients to be marginalized, to languish waiting for evaluation in the emergency department or when trying to make an appointment for a test or specialty visit. While a strong family member or other patient advocate (see our blog about patient advocates) can assume this responsibility, some older people lack such support, and the doctor is their last hope.

In addition, we would add that an elderly patient’s doctor should be very familiar with end-of-life issues. See our newsletter about who speaks for you when you can’t communicate your wishes.

Most of Reznick’s advice pertains pretty much to anyone seeking quality care from a doctor. Who doesn’t want someone compassionate, who doesn’t want someone available? But older people are among the weakest members of society, and often reluctant (or unable) to stand up for themselves. Qualities that are merely preferable for everyone might be critical for them.

To locate a suitable practitioner for an elderly patient:

• Search the Medicare referral site.


• Inquire at the local hospital medical staff office—those folks know who practices what and who’s accepting new Medicare patients.


• Ask people you know whose values are similar to yours.


• Inquire at local and county medical societies.


• Beware of Internet sites such as Yelp and other crowd-sourced referrals—everyone’s experience is different, and if a stranger is making the referral, how do you know your tastes and values are similar?


• Interview prospective doctors; if they decline because they’re too busy, they’re not good candidates.

Health care experts have been saying for 30 years -- ever since a Canadian comprehensive study -- that the annual physical exam is useless and even counter-productive, turning up false alarms that subject patients to unnecessary and even dangerous further testing. Now an article by a physician journalist in the New York Times sums up the evidence and concludes that the annual physical needs to go.

Elisabeth Rosenthal's piece also has a good list of the top 10 tests, starting with the annual physical, that are wasteful and more harmful than good. Here's the list.

Maybe the national conversation about the rationing of health care finally is moving to a more thoughtful plane. Maybe, instead of incendiary language, half-truths and mistruths, Americans, with the help of the medical establishment, are beginning the think rationally about rationing.

As widely reported last week, a panel of physician groups representing the American Board of Internal Medicine Foundation officially recommends that doctors cut back on the routine use of 45 common medical tests and procedures, deeming them often unnecessary and thus more prone to cause harm than good.

As regular readers know, we’ve walked this path many times.

Rationing is neither a new idea nor, necessarily, a bad one. It all depends on context. Doctors and patients who communicate well ration care all the time. One example is “watchful waiting” in the case of a 70-year-old man with prostate cancer, for whom the practice of holding off on treatment in favor of monitoring the status of the disease makes sense unless and until the cancer grows to the point where it would be dangerous to let it continue. Often, these patients live a long life and die of something else, and treating the cancer would cause side effects much worse than living with the disease.

A patient with a sinus infection who wants her doctor to prescribe an antibiotic might be denied because sinus infections often are caused by viruses, which, unlike bacteria, don’t respond to antibiotics, and because even a bacterial sinus infection usually resolves on its own. So the “rationing” of prescription medicine is wholly appropriate in this case.

As medical costs spiral out of control, as insurance premiums match that ascent, rationing makes sense when such care won’t improve someone’s condition, or only incrementally, and with the potential for negative side effects.

As the New York Times explained, the panel, composed of nine medical specialty boards, recommended that doctors perform 45 common tests and procedures less often. It also said patients should question such services if they are offered. Eight other specialty boards, the paper said, are preparing additional procedures their members should perform far less often.

“The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients,” said The Times. “By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.”

Removing the discussion of overused and overpriced tests and treatments from the realm of politics and/or commercial interests (insurance and pharmaceutical companies) and staging it instead on a platform of science confers a welcome sense of authority. Of course, The Times adds, it also reflects the fact that insurers and other entities that pay these costs want to shift more of them to providers, including hospitals and physicians. So, sometimes, it’s in their best interest to rethink a treatment.

To promote critical thinking about what’s necessary and what’s habit, the nine medical boards have created Choosing Wisely in partnership with Consumer Reports. The educational initiative speaks to both medical professionals and patients.

According to the panel, among the overused tests that should be called into question are such procedures as EKGs performed during an annual physical examination when the patient has no symptoms of heart problems, and MRIs or X-rays whenever someone complains of back pain. For the complete list of the initial 45 tests and treatments, link here.

Of course, this isn’t the first time elements of the medical community have suggested reining in the desire to test, test, test. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, and the ongoing debate about the wisdom of regular and invasive prostate cancer tests (see our post here) have caused concern about government interference in personal health-care decisions and the rationing of treatment.

As The Times noted, “Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over malpractice lawsuits…. Clear, evidence-based guidelines like [these] will go far both to reassure physicians and to shield them from litigation.”

We’ve broached the topic of “defensive” medicine as well, concluding that malpractice lawsuits in the wake of a medical error are much less likely if the practitioner takes responsibility, apologizes and assists in rectifying a bad situation.

The solution to too many patients receiving too many tests and costly treatments isn’t about government control, restricting care from people who need it or protecting practitioners against lawsuits. It’s about the thoughtful use of medical resources and putting individual patients’ conditions into context to make informed instead of reflexive decisions. Call it rationing if you want; we call it wisdom.

So much about the health insurance industry is wrong, so much compromises good care and patient safety, that when an underwriter makes the right decision it deserves attention.

WellPoint Inc., according to a recent AP story, plans to boost primary care reimbursement and initiate payment for care management, a patient-protective practice it previously did not cover. The bottom line should be that patients with WellPoint plans will get more quality time with their doctors.

The WellPoint plan will debut later this year and should be implemented throughout its primary care network by the end of 2014.

Primary care practices often receive such low insurance reimbursements that they’re forced to jam as many patient visits as possible into a workday simply to stay financially afloat. We’ve detailed the plight of primary care practitioners, as well as the value of coordinated care.

Care management includes practices such as preparing care plans for people with complex medical problems. It includes simpler practices as well, such as developing an exercise plan for overweight patients, and following up to ensure adherence to it. Care management is a matter of enabling providers to work for patients all along the health continuum instead of addressing only acute needs, of treating people only when they’re sick.

Spending more time with patients facilitates communication, and when patients and doctors communicate well, outcomes improve.

Best practices like these aren’t just about altruism, they’re about saving money, and WellPoint will offer doctors a share in some of the savings realized when better care results in lower costs. Wellpoint officials said the reformulated payments and coverage should reduce some of the most expensive medical care, such as emergency room visits and hospital admissions.

Similar efforts are underway elsewhere in the health-care industry.

Accountable care organizations (ACOs) are becoming more popular as coordinators of care among multiple providers that reduce redundant testing and minimize medical errors. ACOs also afford professional participants a piece of the savings pie.

Insurers are examining the notion of patient-centered medical homes, which are similar to ACOs but focus more on individual practices. Primary care doctors monitor patients between visits and serve as the nexus of communication among specialists and ancillary caregivers, such as nutritionists and physical therapists.

WellPoint has tested the medical home concept and reported that such programs resulted in an 18 percent decrease in hospital admissions and 15 percent decrease in emergency room visits. The company’s new primary care reimbursement plan, AP reported, plans to build on those pilot programs.

Well done, WellPoint. But the effort will have to be embraced by all other insurers in order to become the cultural norm instead of a curiosity.

Once upon a time an adult physical exam routinely included urinalysis, blood tests, echocardiogram and many other screening tests, such as a bone-density scan. But a new study in the Archives of Internal Medicine adds to the growing body of evidence that many such tests are inappropriate, unnecessary and costly beyond their value.

The study, as described by Kaiser Health News, examined the cost of common primary care practices that had been declared overused by a group of physicians known as the Good Stewardship Working Group. It includes internists, family physicians and pediatricians who are part of the National Physicians Alliance, which advocates universal, affordable health care.
Among that group’s conclusions:

• blood and other diagnostic tests were often ordered even for patients who had no related symptoms or risk factors;


• imaging studies such as CT scans or MRIs for low back pain and Pap tests to screen for cervical cancer in teenagers were unnecessary;


• writing prescriptions for antibiotics for children with sore throats who didn't have a strep infection was unwise;


• recommending cough medicines for children with upper respiratory infections and ordering head imaging tests kids who had fallen but didn't exhibit symptoms such as dizziness or loss of consciousness were unnecessary.

The new study estimated that 12 of the unnecessary treatments and screenings cost $6.8 billion in 2009.

The activity most frequently performed without need was a complete blood cell count at a routine physical exam. In more than half of the surveyed routine physicals, doctors inappropriately ordered such tests that cost $32.7 million.

But the single costliest bad practice was prescribing brand-name statins before trying patients on a generic drug first – that accounts for $5.8 billion of the $6.8 billion total.

Study authors said their cost figures were conservative, given that they didn't factor the cost of follow-up tests or procedures prompted by an abnormal blood test reading result or imaging scan, even though in the absence of symptoms or risk factors the follow-up may be unnecessary and even cause harm.

Doctors order unnecessary and overpriced tests and drugs when there's no reason because it’s ingrained in their training, said one member of the Alliance, because some patients expect them and because doctors practice defensive medicine – you don’t get into legal trouble, goes that thinking, if you cover far more bases than you’ll ever need.

Those reasons are misguided on medical, legal and financial grounds.

The new study concludes that doctors alone can't rewrite these misdirections. Patients must inform themselves about when a test is indicated in order to be better medical consumers. And both doctors and patients must communicate. How often have you asked your doctor what the prescription he just prescribed will cost, and he says “I don’t know”?

If your doctor prescribes a test, make sure you know why, what side effects might result and how much it costs. If medication is prescribed, ask if there's a generic version and, if so, if it will suffice, and how much it costs.

Ignorance in standard medical care is not bliss. It's expensive.

As if the doctor-patient relationship isn't one-sided enough, the subservience patients often feel can be made even worse when you must wait way beyond the appointed time for your consultation.

For some patients, time is money, and for all patients whose doctors assume the doctor's time is more important than yours, extended waiting is disrespect. One study last year pegged the average wait time at doctors' offices in the United States at 24 minutes.

Everyone understands that medicine is fraught with emergency, and sometimes a physician simply must accommodate an unexpected patient. But some doctors are never on time; for them, running late is business as usual.

Others are told by superiors and insurance companies to book consultations at 15- or 20-minute intervals; if one patient has more than one problem, or a complication arises that requires 30 minutes' time, every patient after her will be seen late. So, does the doctor cut off the appointment in order to maintain the schedule, or does she meet the medical need at the risk of making everyone else late?

As doctors are increasingly besieged with paperwork demands and lower fees from Medicaid and Medicare, is it fair for patients to expect prompt service? Apart from making a scene, is there recourse when your 10 a.m. appointment begins just before lunch?

Some patients, according to several recent reports including one on CNN, are turning rude behavior into financial penalty. They're invoicing tardy physicians for time spent cooling their heels in the waiting or exam room. And physicians are paying.

Not too long ago, doctors would have scoffed at the idea of reimbursing patients for time spent waiting. But some told CNN they give patients money or a gift, sometimes even without being asked.

"I love this!" Dave deBronkart, co-chair of the Society for Participatory Medicine, told the network. "It's magnificent that some physicians are valuing patients' time. It's a commitment to designing a practice that truly serves patients."

Others ... not so much. One woman left her doctor's office at 8:40 when the gynecologist hadn't shown up for her 8:00 a.m. appointment. Encountering the doctor in the parking lot, the patient asked about the delay. "The doctor told me she had a little one and she was never in the office until ten to nine," she remembers. "I asked her why she scheduled appointments at 8 a.m., and she said to give the patients time to do paperwork. I was so mad I was shaking. I never went back to her."

DeBronkart blogged at E-Patient Dave when he waited 45 minutes for an X-ray. He told CNN that the head of the radiology practice later called and acknowledged the need to change how they scheduled patients.

Some physicians have seen the patient-waiting light, and are doing their best to ensure it isn't red. MedPage Today reported about one who offers Starbucks gift cards and text messages patients if he's running behind. Another, who practices boutique medicine, books only about 10 patients per day for at least 30 minutes each and charges a $125 annual fee per family for the convenience. If he is late, he pays $25.

The MedPage story makes clear that it's easier for some practices, such as surgery, to run more efficiently than a primary care office. Offices at greater risk of being late can address the problem and possibly mollify patients by:

• offering wireless Internet;


• ensuring good cell phone service, and providing space where waiting patients can talk privately;


• texting, emailing and/or calling patients if they're running late.

One patient who tries to turn waiting time into work time is concerned that if billing tardy doctors becomes fashionable they will start charging everyone more. They should focus on prevention, he says.

As a patient, you can minimize your likelihood of a shortened fuse from a longer wait by:

• scheduling your appointment at the beginning of the day or right after lunch;


• locating doctors with demonstrable on-time practices via an organization such as Ideal Medical Practice, which identifies superior practices; and


• putting a value on your time and invoicing your doctor for an unreasonably long wait.

I took a deposition a few days ago that underlined for me why we need to have public report cards on primary care doctors so that patients can separate the mediocre practitioners from the really good ones. I wrote an article explaining the idea. Read my entire piece on Huffington Post, which I called "One Good Reason to Get Mad About Health Care."

The first step in making sure you have a qualified primary care doctor is to check the doctor's board certification credentials. Tragically, Michael Jackson must not have done that, and it may have played a role in his fatal cardiac arrest. The pop singer had a non-board-certified cardiologist right on hand when he collapsed, but the doctor apparently lacked, or didn't use, basic resuscitation equipment. I give more details on this story in a blog entry I wrote for the Huffington Post.

In my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," I spend a chapter talking about all the questions you need to ask to find a top primary care doctor. The very first question is the doctor's basic credentials, which are easily available online from organizations like the American Board of Internal Medicine, which certifies internists and a number of sub-specialties within internal medicine.

There's a new/old take on the importance of primary care doctors to obtaining the best quality medical care. It's called the medical home, and it doesn't mean house calls, but it does mean that the patient has a medical "home" -- a team of providers, led by a primary care doctor, who coordinate the patient's care and know everything that is going on with specialists, testing and followup.

This is new because it's being rejuvenated as a way to cut costs and get higher quality care; it's old because the term was coined by the American Academy of Pediatrics in 1967. Jane Brody reports on this in her personal health column in the New York Times.

The medical home concept is supported by all the medical societies who represent primary care doctors. Unfortunately, over the last few decades, insurance reimbursements have been slanted toward performance of tests and not the painstaking work of listening to the patient, thinking through the patient's problem, and recommending a course of care.

Getting a top primary care doctor is one of the "Necessary Nine" steps for quality care outlined in my book: "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

It sounds like every patient's medical fantasy: Easy access to your doctor 24/7, same-day appointments, thorough and unrushed examinations, little to no time in the waiting room. The only downside is expense: To get this kind of personalized care from a primary doctor, you have to pay an annual fee, and forget about insurance covering it. And you will still need insurance to cover hospital stays and specialists.

Is this ultra-personalized health care, which is called "concierge medical practice," worth it? Many patients think so. Even those squeezed by the recession are often finding room in their budgets for the annual fee for a concierge doctor, even as they cut down on restaurant dinners and other non-essentials.

According to a report by Kevin Sack in the New York Times, leaders in the field of concierge care say they see no impact of the recession in the steady growth of their practices. Dropout rates from the practices are holding steady.

It's estimated there are about 5,000 concierge doctors in the United States, a small fraction of the 240,000 internal medicine doctors in the country. One of the largest groups is called MDVIP, which started in Florida and now has 300-plus physicians in its network. Each MDVIP doctor is limited to 600 patients, who have to pay an annual fee of $1,500 to $1,800. The limit on the number of patients lets the doctors see far fewer patients in a typical day.

The advantage for patients is having a medical expert on hand who knows your body intimately and can sometimes detect subtle danger signs before a full-blown crisis develops.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, finding a top primary care doctor is one of Patrick Malone's key "steps" to finding the best medical care. If it takes extra money to get that relationship, and you can afford it, signing up with a concierge medical practice can be money well spent.