Selection bias

An old doc gives a new model of practice a try.


Fifteen years as a hospitalist, and another ten in an outpatient clinic, had given me quite a bit of experience in the old medicine game. It was time for something new. I was examining options online when I came across an ad for EntourMed, “providing high-profile patients with personalized entourage-level care.” I'd heard about concierge practices, but this was an entire level more intense.

Illustration by David Rosenman
Illustration by David Rosenman

It seemed like a dream opportunity for me. One patient and one patient only, hobnobbing (whatever hobnobbing actually is) with the rich and famous. I pictured celebrity encounters, backstage passes. The challenge would be finding the right patient. Of course, they had an app for that! I signed onto the EntourAPP and began to scroll through my options. I sipped a Chardonnay, petted my chunky cat, Phatty, and began to explore my options.

I needed to create my own profile. First there were my demographics. I was near geriatric myself, but not quite. There was a section for training and publications. There was also an area for personal details, from hobbies to athletics. There was even a “get to know your doc” section where you could post a picture that demonstrated your nonmedical side. A quick selfie of me and Phatty and I was done. I pressed enter and began to scroll through my patient options. I could click once for accept, twice for neutral, or three times for “no way.”

The celebrity patients came in categories. What would it be: Politician, Musician, or Hollywood Star? There were some other options, such as White-Collar Criminal, Internet Celebrity, or Medicare Executive, but these all seemed too shady. After much deliberation, I found myself leaning towards Musician. I just loved to shake a leg!

Now it was time to get into patient demographics. Would I want a male or female patient? I really had no preference. Should the patient be young or old? I considered that a younger performing patient would be more likely to be a rap star and I was more of a traditional blues type, so I opted for over 65. I was a certified geriatrician; it made sense to aim for that age range.

Here's where it got tricky. There were a lot more options to go through. Smoker? Triple click: too likely to get sick. Under the alcohol section, I triple clicked on heavy. Drugs were an easy triple click as well. I didn't want to deal with that. Exercise was more problematic. I wanted someone active, but not a triathlete who would drag me to events all over the globe and expect me to keep up and deal with the orthopedic consequences. I selected sedentary to moderately active, and triple clicked on the marathoners.

When it came to disease states, I was less picky. Diabetes, hypertension, hyperlipidemia were all single clicks. COPD and CHF were double clicks; I'd manage them but would be happy to avoid constant hospital admissions. Past medical history, family and social history, and allergies were all up for review. I felt they were not essential either way so I single clicked along. It was easier without a preference. There was a section for emergency department and hospital usage. I didn't want a frequent flier, but whomever I selected, I'd be sure to manage their symptoms and keep them out of trouble. Finally, there was region of the country or the world. I was ready to go anywhere.

Three hours later, I had completed my ideal patient profile and my patient options were available. There was an old cowboy singer who was a weak match due to his recreational marijuana use. There was a retired opera diva famous for her outrageous outfits (but her ED usage was very heavy) and a bassist for a famous rock band who was perfect except for his three-pack-a-day habit. I was feeling like I might have to change my settings and pick a less optimal patient, but I hadn't quite exhausted all the options.

There were crooners and baritones, balladeers and rockers, lounge singers and lyric sopranos. Finally I found the perfect patient. She had fronted a British rock band in the 1970s. She was diabetic with a decent glycohemoglobin and a moderate drinker but a nonsmoker. She exercised rarely and had high cholesterol. And she was still performing. I happily single clicked!

Meanwhile, singer Leticia Crowley-Smythe was scrolling through EntourMed, looking for a geriatrician who had trained at a well-known medical center. She came to Dr. N. He was bald and gray-bearded—that was good. He had trained at Hopkins and Mayo—both good. Lots of publications in something called ACP Hospitalist—perfect. This could be her ideal physician.

She was about to click on him when she opened the “get to know your doc” section.

There he was with his kitty named Phatty.

A cat? With a dumb name?

Yuck. Triple click.