Scenes From the 21-st Century Doctor's Office
Having health insurance doesn't ensure it will be easy to find a doctor
Tuesday, March 9, 2010
It seemed like a relatively simple process: When you get sick, first call your primary-care doctor. Second, visit said doctor. Third, follow doctor's orders: Fill prescriptions, take to bed, whatever. Fourth, get better.
But what if you can't even get past Step 1?
I struggled with this problem for more than a year. After graduating from college, I returned to Washington in 2007. I'd grown up in Bethesda and used a doctor in Kensington during high school. But the journey from my office in Adams Morgan out there took about an hour and a half for car-free me. It was time to find a medical practice in the city.
Naturally, I waited until I wasn't feeling well to seriously initiate this process. But I didn't expect any problems. I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of preapproved doctors and started calling.
And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.)
I talked to one primary-care practice that hadn't accepted new patients in eight years. I talked to another that was accepting new patients only if they had HIV/AIDS.
Ah, so that's what it took to get a doctor within reach: I just had to contract a deadly disease.
I first began calling practices in 2008. Truth be told, I can't even recall what was bugging me: The symptoms always dissipated before I could find a doctor who'd accept me, or I'd just suffer through.
But in early 2009, I renewed the effort, hoping to meet with a doctor to discuss stomach problems that had persisted all fall. No luck. I invested half a workday heading out to my old doctor in Kensington. That spring, I again wanted an appointment after my insomnia suddenly intensified. (It's something I've dealt with since high school.) Once more, I journeyed midday to Kensington.
It was time to take a concerted, organized approach. I turned to my mother.
Or rather, she offered to help. As a teacher with the summer off, she had time to spare. About two weeks later, she produced a list of some 15 practices in the District that she had contacted. Only two were accepting new patients with insurance coverage like mine. But they came with relatively poor online reviews -- one doctor was described as "socially awkward" and the other was said to have a brusque staff and exam rooms covered with piles of paperwork.
At that point, I came to a conclusion: This search was officially too hard. And if Congress eventually passes any kind of health-care reform that gives coverage to millions more people, searches like mine are only going to get harder. An influx of patients will overwhelm a system already crippled by a well-documented dearth of primary-care physicians, as medical students gravitate toward more lucrative specialties. Look at Massachusetts, where a mandate for health insurance has brought the coverage rate to 97 percent. In the Boston area, patients wait 63 days, on average, to see a family doctor, according to a 2009 survey. This figure topped the list, far ahead of Washington's 30 days and New York's 24 days.
For the most part, health-care reform in Massachusetts has "been a really great thing," says Joseph Gravel, president-elect of the Association of Family Medicine Residency Directors. "The only downside to it really is that there hasn't been enough attention paid to: Do we have the capability or the capacity?"
Throughout my own quest for a doctor, and as I began writing this article, I'd bring up the issue with friends. Later, fully willing to impose on people with the promise of anonymity, I sent out a questionnaire.
And what good friends they were: Tales of untreated urinary tract infections, among other things, soon filled my inbox.
One friend got a UTI just after she'd moved to Washington and was waiting for her new medical insurance card to arrive. After a week of pain, she saw a doctor at a CVS MinuteClinic in Bethesda. But her symptoms returned two weeks later. "By this point I was desperate," she wrote to me. "I started calling every doctor listed on my insurance company's website. I must have made 20 phone calls before I found a doctor that would let me come in. I think I waited about 2 days to see him."
Other friends searched during less frantic circumstances: One pal, who works in Bethesda, first looked for an available primary-care physician in her plan in Maryland but gave up after numerous futile phone calls. This year, she tried Virginia doctors and soon "was able to schedule two physicals with two different doctors and cancel the less convenient one," she wrote to me.
Another friend similarly remarked that finding a doctor was much easier south of the Potomac. And still another had never searched, fully avoiding the hassle. "Was not insured growing up, went to doctors very sporadically" he wrote.
Experts have long contemplated how to increase the number of primary-care physicians. Bob Phillips Jr., director of Washington's Robert Graham Center, which studies family medicine and primary care, says medical schools could help boost the number of graduates going into primary care by being more discriminating about which applicants they admit.
Phillips, who is also a family physician in Fairfax, says medical students are more likely to choose primary care "if they are from a rural area, if they are older and have other life experiences, if they're married and, interestingly, if they're female, and if they come from a family of lower income -- not if they're necessarily poor, but if they come from a family not of the higher-income categories."
Gravel has an immediate solution: Fund more primary-care residents. "If we get more family medicine residents and primary-care residents," he says, "we'll have more primary-care doctors."
Phillips acknowledges that it's already nearly impossible to find an open primary-care practice in the District.
The Department of Health and Human Services keeps a list of places around the country that are short of primary-care providers. Each of these "Health Professional Shortage Areas" is given a score of 1 to 25, with a higher score representing a greater need. The District has a number of HPSAs; among them are Mt. Pleasant/Upper Cardozo (score 16), Anacostia (20) and downtown's homeless population (13).
But the shortage is felt acutely even for people willing to look all over the city -- people like me.
"D.C. is a little bit unique," says Phillips. Office rents in the city are very high, while primary-care physicians here are paid poorly. "That combination means . . . finding a primary-care physician . . . in D.C. is rare; it's so rare."
Even for the high and mighty.
Phillips's group has lobbyists who meet regularly with members of Congress and their aides. They'll occasionally return from these meetings having gotten a familiar request: "Hey, I have a family physician back home, or I have a general internist, and I can't find one [here]. Can you help me out?" says Phillips. In the last nine years, he's heard from about five members of Congress and some 50 staff members. He tells them to do exactly what I had been doing when all else failed: head to the suburbs.
"I've wound up getting them seen usually in Northern Virginia or Southern Maryland," he says. "I have not been successful in connecting a member of Congress with a primary-care physician in the District."
In the end, I proved more adept than Phillips at finding a physician inside the District who was in my insurance plan. In early December, I plunked down in an examining room at a Capitol Hill practice for my first physical in three or four years.
The moment I'd scheduled the appointment, I felt relieved. I had a good feeling about this. And by "good feeling," I mean that unless this doctor made me doubt the validity of her medical degree, I would be satisfied.
And I was more than satisfied. The exam was comprehensive and didn't feel rushed. The practice, Washington Primary Care Physicians in Eastern Market, was located directly across the street from an Orange Line Metro station. I was able to get an appointment because the doctor I saw, Anna Zamskaya, had just started there.
I called Zamskaya later to ask her about working in the District. (She'd practiced in Northern Virginia before.) She said she'd heard other patients complain that it was tough to get an appointment in Washington.
"I always feel that if you need to see a doctor, and you need to drive somewhere 10 minutes longer, it's not that big of a deal. There are a lot of practices everywhere. But then again, I haven't tried," she said.
Zamskaya says she personally doesn't keep track of the number of patients she has seen, and it's hard to predict when she'll have a full patient load.
I have a feeling it won't take long.