At 64, Dr. Shaefer has been an internist for more than 30 years.He entered practice at the end of what has since been termed the\"golden age\" of medicine, before DRGs and managed care, whenphysicians made treatment decisions and carried them throughunchallenged by third parties. After completing his residency, hejoined a small group practice in the same city. The group practicehas since grown to more than 20 physicians. Along the way, Dr.Shaefer was able to join the faculty at a local medical school as aclinical instructor. The position forced him to stay current withdevelopments in general internal medicine and exposed him to newgenerations of students with diverse backgrounds and ideas. He wasa conscientious teacher, committed to evidence-based medicine, anda caring practitioner, treating the person, not the disease.
Dr. Shaefer's children are well beyond college (one is now aphysician, too) and have children of their own. Dr. Shaefer wantsto spend more time with his family and has thought about retiringbut wants to continue caring for patients in a less demandingenvironment. In reflecting on his career, he finds that practicingmedicine is not as rewarding as it once was: it seems to be moreabout rushing patients in and out the door, securingpre-certifications, begging insurers to reconsider theirreimbursement denials, explaining why the pill someone sawadvertised on television is not really a magic bullet, and fillingout paperwork—endless paperwork.
Dr. Shaefer is the first in his office to decide he is going tochange how he practices. He is going to form a retainer practice,and reduce his patient panel from 3000 to 600. Over the next 6months, he will write to all of his patients to explain that he istransforming his practice in order to provide enhanced patientcare, and to invite those who are willing to pay an annual fee of$2000 to remain as his patients. Patients who join the \"retainerpractice,\" as it is called, will still be reimbursed by theirinsurance plans for those medical services that the plan covers.But insurance will not reimburse the \"extra\" services Dr. Shaeferwould like to perform, accompanying patients to appointments withspecialists, for example, providing more preventive care, andforming closer relationships with patients than he has been able todo of late. He wishes he could provide all his patients this samelevel of care, but he cannot. He will assist those who do not jointhe retainer practice in finding new physicians. Dr. Shafer hastalked to his colleagues to ensure that they can take on those whodo not join his new practice.
As he sees it, there are personal and professional reasons forundertaking this controversial change. He's getting older, he'sdone his share of pro bono work, and has contributed to educatingthe next generation of physicians. Some patients won't like thechange, but they would have had to find another doctor had heretired. Through their choice to stay in his practice, those whopay will have validated his decision.
What is the bioethics issue(s) in this case? Whatwould you advise Dr. Shaefer to do?
