Robin Cook: Crisis

"I suppose," Jack said without a lot of enthusiasm. Just thinking about the heat of the island's interior made him feel thirsty. He sat up. "I'm going to get something to drink. Want me to bring you back something?"

"Are you going to have one of those mojitos?"

"I'm tempted," Jack said.

"You really are on vacation," Laurie said. "All right. If you're game, I am, too. I just might have to nap this afternoon."

"Nothing wrong with that," Jack said. He got to his feet and stretched. What he really needed to do was rent a bike and go for a serious ride, but that thought stayed with him only halfway to the bar. Lazily, he decided he'd look into it tomorrow.

Catching the eye of one of the bartenders, Jack ordered the two drinks. It was exceptional for him to drink at all, much less in the afternoon, but he'd been encouraged to try it the day before, and he'd enjoyed the utterly relaxed feeling the alcohol had given him.

While he waited, Jack's eyes wandered around the pool area. There were a few women with world-class figures that encouraged a brief appreciative glance. His eyes then wandered out to the broad expanse of the Caribbean Sea. There was a slight, silky breeze.

"Your drinks, sir," the bartender said, catching Jack's attention. Jack signed the check and picked up his drinks. As he started to turn back toward the pool, his eyes caught the face of a man across the peninsula-shaped bar. Jack did a double take. He leaned forward and unabashedly stared. The man's eyes briefly engaged Jack's but without recognition and were soon redirected to the handsome Latin woman sitting next to him. Jack watched him laugh with easy grace.

Jack shrugged, turned again, and started back to his lounge chair, but he got only a few steps before he turned again. Making up his mind to get a closer look, Jack walked around the bar and approached the man from the rear. He advanced until he was directly behind the individual. He could hear him speaking. It was passable Spanish, certainly better than Jack could muster.

"Craig?" Jack said, loud enough for the man to hear, but the individual did not turn around. "Craig Bowman," Jack said a tad louder. Still there was no response. Jack looked down at the two drinks he was holding, which were restricting his options. After another short debate, Jack leaned into the bar on the side of the man opposite his companion. Jack put one of the drinks on the bar and tapped the man on the shoulder. The man swung around and met Jack's gaze. There was no recognition, only a question with eyebrows raised and forehead furrowed.

"Can I help you?" the man questioned in English.

"Craig?" Jack questioned, watching the man's eyes. As a former ophthalmologist, Jack tended to look at people's eyes. The same way they often gave hints of general illness, they could give hints of emotion. Jack saw no change. The pupils remained exactly the same size.

"I believe you have me confused with someone else. My name is Ralph Landrum."

"Sorry," Jack said. "I didn't mean to be a pest."

"No problem," Ralph said. "What's your name?"

"Jack Stapleton. Where are you from?"

" Boston originally. How about yourself?"

" New York City," Jack said. "Are you staying here at the Nacional?"

"No," Ralph said. "I've rented a house just out of town. I'm involved in the cigar business. How about yourself?"

"I'm a medical doctor."

Ralph leaned back so Jack could see his lady friend. "This is Toya."

Jack shook hands with Toya across the front of Ralph.

"Nice to meet you both," Jack said after stumbling through a little Spanish for Toya's benefit. He picked up his drink. "Sorry to be intrusive."

"Hey, no problem," Ralph said. "This is Cuba. People expect you to talk with them."

With a final nod, Jack took his leave. He skirted the bar and returned to Laurie. She pushed herself up on one elbow and took one of the drinks. "It took you long enough," she said jokingly.

Jack sat down on his lounge chair and shook his head. "Have you ever run across someone, and you are sure they are someone you know?"

"A few times," Laurie said, taking a sip of her drink. "Why do you ask?"

"Because it just happened to me," Jack said. "Can you see that man talking with that buxom woman in red on the other side of the bar?" Jack pointed toward the couple.

Laurie pulled her feet around, sat up, and looked. "Yeah, I can see them."

"I was sure that was Craig Bowman," Jack said with a short laugh. "He looks enough like him to be his twin."

"I thought you said Craig Bowman had sandy-colored hair similar to yours. That fellow has dark hair."

"Well, except for the hair," Jack said. "It's incredible. It makes me question my impressions."

Laurie turned back to Jack. "Why is it so incredible? Cuba would be a good place for someone like Craig to go. There is certainly no extradition treaty with the United States. Maybe it is Craig Bowman."

"No, it's not," Jack said. "I had the nerve to ask him and watch his response."

"Well, don't let it worry you," Laurie said. She regained her reclining position, drink in hand.

"It's not going to worry me," Jack said. He, too, lay back on his chair. But he couldn't get the coincidence out of his mind. All at once, he had an idea. Sitting up, he fumbled in the pocket of his robe and pulled out his cell phone.

Laurie had sensed his sudden motion and opened one eye. "Who are you calling?"

"Alexis," Jack said. She answered but told Jack she couldn't talk and that she was between sessions.

"I just have a quick question," Jack said. "Do you by any chance know a Ralph Landrum from Boston?"

"I did," Alexis said. "Listen, Jack, I really have to go. I'll call you in a couple of hours."

"Why did you put it in the past tense?" Jack asked.

"Because he died," Alexis said. "He was one of Craig's patients who died of a lymphoma about a year ago."

Concierge medicine (also known as retainer medicine or boutique medicine or luxury primary care) is a relatively new phenomenon that first appeared in Seattle. As described in Crisis, it is a style of primary-care medical practice that requires an annual membership fee that varies from hundreds to many thousands of dollars per person (the median being about $1,500 and the maximum about $20,000). In order for this fee not to be construed as a health-insurance premium, which would be against regulations, the patient is offered a laundry list of specified medical attention or services not covered by health insurance, for example, elaborate yearly physicals, preventive care, nutrition counseling, and individually tailored wellness programs to name a few. But the real perk stems from the physician's guarantee to limit enrollment in the practice to a number far less than usual, making possible special amenities and special access to standard medical services (but not payment, which remains the responsibility of the patient either through health insurance or out of pocket).

The amenities might include: a very personal doctor-patient relationship, unhurried appointments that are as long as needed, nicer and uncrowded reception areas (not called waiting rooms since as an amenity waiting is to be avoided), house calls or patient office visits if appropriate and desirable, facilitation of appointments to needed specialists and immediate consultation, and even possible travel by the doctor to distant locales if the patient becomes ill or injured on a trip. Special access includes same-day appointments if needed or certainly within just a day or so, and twenty-four-hour doctor accessibility with the doctor's cell phone, home phone, and e-mail address.

There have been a few articles about concierge medicine in professional journals as well as in The New York Times and other mass media publications, but, for the most part, the slowly burgeoning practice style has gone unnoticed by the vast majority of the public. I believe this will and should change, because concierge medicine is yet another subtle but significant symptom of a healthcare system that is out of whack since good, patient-oriented medicine used to be available, and should be available, without a considerable up-front fee. More important it is common knowledge there are already significant inequities involving healthcare access worldwide, and one doesn't have to be the proverbial "rocket scientist" to understand that concierge medicine will make a bad situation only that much worse: Those doctors practicing in this style will, by definition, see far fewer patients, and all those patients who do not come up with the retainer fee for whatever reason will face less choice in a further constrained system. Indeed, a handful of U.S. senators officially complained to the Department of Health and Human Services about the phenomenon's potential impact on limiting the ability of Medicare recipients to find a primary-care physician. In response, the Government Accountability Office issued a report in August of 2005 suggesting that concierge medicine was not yet a problem, but that the trend would be monitored. The implication was that there will be a problem as the practice style mushrooms. Unfortunately, I can personally attest that it has already reached this situation in Naples, Florida, where concierge medicine has taken root. Currently in Naples, it is difficult for a new Medicare patient to find a physician without anteing up the requisite concierge retainer, or paying an exorbitant, out-of-pocket yearly physical fee, or opting out of Medicare altogether. Although Naples is admittedly a unique community economically, I believe it is a harbinger of what is to come in other communities both in the U.S. and internationally as well.