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Patients' Plight: Where Are the Doctors?

Posted on: Friday, 1 July 2005, 09:00 CDT

Jun. 30--When Elliott Abbott received a letter this spring saying his primary care doctor was leaving Cape Cod, he was disappointed but not worried.

Abbott, who is on the board of the American Cancer Society of the Cape and Islands, gave high marks to Dr. John Malolepszy, who is moving to the Boston area, but Abbott figured it would be fairly easy to replace the internist with another physician.

Instead, the Yarmouthport resident joined the ranks of hundreds, possibly thousands, of Cape Codders who are searching for new doctors in the face of a Capewide shortage of primary care physicians.

"I've called about 10 doctors looking for primary care physicians," Abbott said shortly after getting his "Dear patient" letter from Malolepszy. "They all gave the same answers: 'We're slammed.'" Doctors are either not accepting new patients or are scheduling first appointments five or six months out, he said.

"Apparently, it's a crisis situation," said Abbott, who has been treated for minor skin cancers. "It's a big concern. You have to go through your primary care physician for all your referrals to specialists -- anything, mammograms, radiologists. What if we don't have access to a PCP for help with early diagnosis of cancer? Early detection? If you discover a lump in the shower, do you go to the emergency room? I don't think so."

In the past couple of years, about one dozen primary care doctors on the Cape have closed their doors -- several within the past few months. They have retired, moved off Cape, left the state or changed jobs, as in the case of two doctors who left private practice to become "hospitalists" on staff at Cape Cod Hospital.

Remaining physician practices, such as Emerald Physician Services in Hyannis, are being deluged by displaced patients.

"We're getting on average 30 new patients a day," said Dr. Cormac Coyle, Emerald's medical director.

"That's been going on for two months now. We just can't meet that kind of demand.

Emerald practice manager Karen Mercer said the practice normally prides itself on seeing new patients within a month. That's not possible now, she said. "We're looking at March and April now. We're trying to accommodate them. There's panic out there."

The need for more primary care doctors is nationwide. The crisislike situation on the Cape is compounded by the area's high cost of living -- including home prices -- coupled with a stagnant rate of reimbursement and the complexity of serving the Cape's aging population.

"It's extremely hard in the Northeast," said Dr. Mary Frank, president of the American Academy of Family Physicians.

But it's not just the high cost of living and running a business that's putting the squeeze on primary care doctors in New England, she said.

The big teaching hospitals in Boston and Providence draw thousands of medical graduates into training for subspecialties that offer more money and fewer insurance reimbursement headaches. That has translated into fewer medical residents choosing family practice medicine or primary care internal medicine within the past few years.

Frank said a family physician meeting face to face with a patient typically will receive $40 in reimbursement for a 15-minute appointment. A cardiologist or gastroenterologist will get $200 for running a test or procedure in the same 15 minutes.

"That's what begins to really skew the reimbursement," said Frank, who practices medicine in California. "When students see primary care doctors have to work longer hours, and they don't get paid half of what they'd get paid as a dermatologist or radiologist, they think, 'Why should I pick that specialty (family medicine or primary care)?'"

On the Cape, primary care physicians also face the challenge of a rapidly aging population. Although baby boomers are driving the aging of America, Cape Cod is ahead of the curve, with Barnstable County the oldest county in the state. Orleans is the oldest town in Massachusetts.

With older patients, "the complexity of medical care just grows and grows," said Dr. Enrico Versace, who left private practice to become a staff doctor at Cape Cod Hospital late this winter. A cardiologist deals with a heart patient, he said. An internist manages the care for the same patient's heart problems, diabetes and lung disease -- for lower reimbursement and while being under the gun timewise.

"The more time you spend with a patient, the more it becomes financially inefficient," Versace said about his private-practice days. "The system kind of sets you in a position to incorporate more technology and try to shuffle through as many patients as you can."

Not only is the Cape population aging, it is growing rapidly.

Strategists at Cape Cod Healthcare Inc., the parent company of Falmouth and Cape Cod hospitals, have figured that, based on population and need, the Upper and Mid-Cape are short about one dozen primary care physicians.

David Reilly, spokesman for Cape Cod Healthcare, said the organization figures the Mid- to Outer Cape could use six more primary care physicians than the 60 it already has affiliated with Cape Cod Hospital.

But at least the number of internists and primary care doctors affiliated with Cape Cod Hospital has grown by 11 since 2001.

On the Upper Cape, which is served by Falmouth Hospital, the number of primary care doctors affiliated with that hospital has declined over the past four years by four physicians, to a current total of 41. Reilly said market analysis showed the area should have 47 primary care doctors or internists.

Reilly said that three dozen or so doctors are still accepting new patients, but wait times for appointments are increasing.

Marstons Mills resident Rita Robustelli, 79, said that Cape Cod Healthcare's list of physicians who are taking new patients is outdated. She said she has called four doctors' offices listed, only to be told they had reached maximum overload or didn't take her insurance.

"I said (to a medical receptionist) I have a list here. Your name is on it," said Robustelli. "The girl said, 'Absolutely not.'"

The office assistant at a Mashpee practice told her she wouldn't be able to see the doctor, but she could make an appointment with one of his physician assistants.

Robustelli finally was able to schedule an appointment with a physician in Hyannis in July -- but only because she agreed to be seen very early in the day, at 7 a.m.

"I do need a doctor," Robustelli said. She said she's in fairly good health but has had both knees replaced and has some problems with water retention. "I am not going to be going to the emergency room every time something doesn't feel right."

GUIDELINES FOR FINDING NEW DOCTOR

NEED A DOCTOR?

First, compile names of physicians accepting new patients. Your former physician might be able to supply names.

If not, call the information line at Cape Cod Healthcare Inc. (1-877-CAPE-COD), the parent company of Cape Cod and Falmouth hospitals. Information line manager Jan Aubrey keeps a list of primary care doctors accepting new patients.

Or try the "find a physician" feature on Cape Cod Healthcare's Web site (www.capecodhealth.org). The list of doctors accepting new patients is fairly current, although at least one doctor (Dr. Eric Weber) on the site can no longer accept new patients because his available slots filled up so quickly.

FOUND A DOCTOR?

You may have to wait months for that introductory appointment. Here are several tactics you can try to shorten the wait:

--See if there are any openings at odd hours of the day -- 7 a.m., for instance -- or ask to be contacted should an already scheduled appointment for another patient be canceled.

--Ask if seeing a nurse practitioner or physician assistant will get you in the door sooner. Once you've seen the NP or PA, you can request a medical doctor in the future.

--Tell the doctor's office assistant if you have pressing medical problems that require more immediate attention. Sometimes that can make a difference in the scheduling process.

--If your health requires that you see a doctor immediately, go to the emergency room or a walk-in medical clinic, depending on the severity of the problem. The ER or clinic staff might be able to help you get a follow-up appointment with a primary care doctor.

WHICH SPECIALTY EARNS THE MOST?

In their book "Will the Last Physician in America Please Turn Out the Lights?" authors James Merrit, Joseph Hawkins and Phillip Miller say physician salary levels are not the problem. The issue is the disparity between primary care salaries and specialist salaries.

Below are 2004 average annual incomes:

Family practitioner -- $146,000

Pediatrician (also considered primary care doctors for the younger set) -- $144,000

Internist -- $162,000

Urologist -- $277,000

Cardiologist -- $292,000

Anesthesiologist -- $305,000

Radiologist -- $317,000

The authors say it's no wonder that medical school graduates increasingly choose subspecialty care as their future. The National Resident Matching Program bears witness to this decision-making.

In the group's report on residency "matches" this spring, the number of medical school graduates selecting "primary care" residencies has declined from 369 in 2001 to 280 in 2005.

Of those matches, U.S. medical school seniors made up 170; the other 110 positions were filled either by graduates of foreign medical schools or osteopathic schools.

In family practice residencies, 2,275 positions were filled this spring, 71 positions fewer than in 2001.

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Copyright (c) 2005, Cape Cod Times, Hyannis, Mass.

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Source: Cape Cod Times

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