Still, she finds the trend toward selective care troubling. In many communities across the country, Tolle said, there aren't enough primary care doctors, which means that boutique providers seeing fewer patients are making it harder on other doctors and the people they treat.
"The justice-and-ethics issue is not that some people get more - that you buy a Cadillac instead of a Honda," she said. "The result is that some people get less. I'm talking about when those individuals do not carry their share of the poor and uninsured and underinsured because they're only doing boutique."
The American Medical Association's Council on Ethical and Judicial Affairs issued a report at the group's interim meeting last week outlining guidelines for what it refers to as "contracted" medical services.
Dr. Leonard J. Morse, the council chairman, said the report acknowledges a doctor's right to practice such medicine but stresses that he or she still has a responsibility to serve the broader community. Under the proposed guidelines, a boutique doctor would be obligated, for instance, to treat anyone who shows up in the office with a medical emergency - even if he or she isn't a "member."
The guidelines prompted such lively debate that the council was asked to revise them; the report will be reintroduced at the AMA's annual meeting in the summer. More boutique practices are expected to spring up before then, including some in California and Washington.
At Executive Physician Services in suburban Rochester, N.Y., Dr. Paul R. DiEgidio sees patients whenever and wherever they want - including their home or office.
He offers two levels of care: "standard," which costs $2,500 for an individual, or "platinum," which costs $5,000. The less expensive plan gets patients his pager number; the more expensive one gives patients his cell phone number.
DiEgidio, 42, has been to patients' houses after midnight for emergencies. Recently, he delivered a set of crutches, a cane and a prescription to the wife of a patient experiencing knee pain so he would have them when he got off a plane from a trip to Hong Kong.
For visits at patients' offices, DiEgidio dresses as they dress: in a suit and tie or more casually, if need be, so he blends in. He carries everything he needs in a briefcase. Since May, he has signed up 15 paying clients and hopes to attract 100 to 300. He sees an additional five at no charge because he can afford to and has the flexibility.
He has heard plenty of criticism about boutique care but says the arrangement allows him to take care of patients the way he wants to - and the way they want him to.
"I think doctors should be able to do anything they want. It's their life and their business, and to be altruistic and say they have some type of obligation here or obligation there, that's not necessarily true anymore," he said. "[People] expect of doctors things that they don't expect of any other profession."
The `extra mile'
Dr. Elizabeth R. Vaughan closed her internal medicine practice in Martinsville, Va., last month because she was working so hard it was making her sick - and for less money every year, she said. Now, she practices boutique medicine in Greensboro, N.C., offering patients terry cloth robes and green tea in a lounge with glass furniture that makes it look more like a living room than a medical office. She plans on paying her patients $1 for every minute she is late for an appointment.
"Their time is valuable," said the 50-year-old physician, who charges $1,500 a year for an individual membership and $185 an hour for follow-up visits.
She said that switching to concierge care - she prefers that term because it emphasizes how she goes "the extra mile" - was one of the hardest decisions she ever had to make because she knew that many former patients wouldn't be able to afford her anymore. She tried to get someone to take over her practice to no avail.
"Life is not fair," she said. "Some people belong to country clubs, other people go to beer joints to get together. The medical system in this country has always been stratified. If you have money, you always have more choice. And that's in medicine, politics, business, everything. I have taken care of the salt of the earth for a very long time, and I loved it. But I'm ready to do something different."