Retaining a Love
of Caring for Patients
by Mark Thornton, MD
January 1, 2008. It’s my five year anniversary.
It’s hard to believe that I opened the doors to
San Antonio’s first retainer practice that long
ago. Some people refer to them as “concierge” or “boutique” practices.
I think that “retainer” captures the concept better.
Patients pay an annual fee to be a part of the
practice. For that fee they receive exams and/or services
that are not available in normal practices.
I had practiced General Internal Medicine as part
of what became a seven member group for almost
20 years. I was seeing 25 patients a day, sometimes
30 on a busy day, when Medicare announced that
they were cutting reimbursements. Our overhead
was increasing, and I was already starting to feel
burned out from keeping that pace. A friend
described it as “a white collar sweat shop.”
I thought of retraining, but fundamentally I liked
what I did. I just didn’t like the feeling that I was
running patients through like cattle. I had no time
to really focus on prevention. All my time seemed
to be spent putting out fires.
I found an article from the Wall Street Journal
that I had read several years ago that described
the concept. There was a company called MDVIP
mentioned in the article. They are basically a franchiser
of retainer practices. They collect the payment
for the annual fee and take a third in
exchange for helping to convert an existing practice
to a retainer practice.
I contacted them, and they were willing to evaluate
my practice. After reviewing data that I supplied to
them, they came to San Antonio to meet with me.
They were excited about the prospect of entering a
new market. Most of their practices were concentrated
in Florida, with a few along the East Coast. I was
turned off by three men in suits who spoke of a “winwin”
situation. I was distrustful of letting someone
else collect the money and pay me on a monthly
basis. Twenty years of dealing with insurance companies
had taught me to be skeptical. I consulted with
several of my patients who were successful businessmen.
They liked the concept but encouraged me to
do it on my own. When the suits from MDVIP mentioned
a non-compete agreement, that cinched it. I
was going to do it on my own.
I spent the next year meeting with attorneys, real
estate agents, architects, contractors, software salesmen
and bankers. It was a great exercise, rethinking
my practice. I thought of all the complaints that I
had heard over the years from patients about what
they didn’t like about going to the doctor. I thought
about all of the impediments that discourage people
from seeing a physician: parking, waiting,
phones, staff, and access among them.
My partners were supportive. They understood
my reasons for wanting to change. They agreed to
take care of whatever patients of mine decided not
to join the new practice. Finally, I was ready to let
my patients know what I was planning to do. I sent
out a letter to my 3,000 patients explaining my reasons
for leaving the group, what I was planning to
do, and when I was planning on doing it. I decided
to limit the practice size to 600 patients. This was
based on the number of patients in a busy
internist’s practice when I started in 1983. I also
decided that a certain percentage of patients in the
practice would not pay an annual fee. I felt that for
certain longstanding patients, changing doctors at
this stage of life would be too traumatic. I wanted
to keep them in the practice, even if they were not
able to pay. The response came quickly, positive and
negative. The Express-News ran a front page article.
There was no turning back.
It was a very emotional experience. I had to set
aside more time for my appointments so that I could
say goodbye. I learned a lot. I was surprised by some
of the patients who could well afford the retainer who
did not join the practice, and those patients of modest
means who did. My colleagues were encouraging,
for the most part. Most comments were positive. Most of the negative comments I heard were second-hand.
I set up my office in a retail center. My patients can park
in front and walk right in. I made my office soothing and
tranquil. The waiting room doesn’t feel like a waiting room.
There’s no glass window separating the patients from the
staff. I have one receptionist and a nurse. I have an electronic
medical record system. All of my patients have my phone
number, cell number, and email address. Doctors always ask
me about that. I tell them that people don’t want to wake
me up in the middle of the night for something trivial. They
know that I’m there for them and they don’t want to take
advantage of the arrangement. Some of the needy patients
called at first to see if I really answered. When they knew
that I did, they didn’t feel the need to call as much. Part of
their anxiety came from not knowing whether or not they
could get in touch with someone when they felt they were
sick. Rarely, I have had to educate patients about what is and
is not appropriate to call about after hours.
I started with 200 patients. A year later, I had 300. Now
my practice is full, with a waiting list. Turnover is less than
5 percent per year. I always had thought that I would have
a partner, but the right one hasn’t come along, and now it
seems less important. Students don’t choose General
Internal Medicine. They want to be a subspecialist or hospitalist.
It’s sad to see what has happened to my specialty.
For now, the office is nice and quiet, not at all like the frenetic
office that I left behind.
There are a few other physicians who have set up similar
practices. Some of them have sought my advice. I don’t
know how successful they have been, but I wish them well.
Was it worth it? Yes. I spend about the same number of
hours in the office, but with about half the number of
appointments. I have the time I always thought I would
have when I was in medical school to spend with patients.
As everyone in primary care knows, much of the time we
spend is coordinating care. I now have the time to do that,
as well as make the occasional house call like I did with
my father when I was a boy. My schedule is more flexible,
and it is easier to attend my children’s sporting events and
fit in time for charitable work.
Financially, I’m more successful, but it’s more about
being in control and enjoying what one does than making
more money. Really.
I love being a doctor again.
Dr. Mark Thornton is a native of San Antonio.
His late father, Dr. Mel Thornton, practiced
pediatrics in San Antonio for many years. Dr.
Mark Thornton graduated from the University
of Texas in Austin and the University of Texas
Medical Branch in Galveston, Texas. He
remained in Galveston for his residency,
returning to San Antonio in 1983, one day before a hurricane hit.
He married a Canadian, or more precisely, a Torontonian. They
have a 15-year-old son who makes movies and a 13-year-old
daughter, a sports enthusiast, who briefly considered a medical
career. Dr. Thornton likes to exercise, travel and garden in the
little free time that he has.
