Hospital doctors shut doors to new patients

Most primary care physicians at Boston's top-tier teaching hospitals are so busy that they have officially closed their practices to new patients.

Callers to Massachusetts General Hospital's physician referral line, for example, are told that all, or almost all, of the hospital's 178 primary care physicians are not accepting more patients. All 42 internists at Boston Medical Center have had full lists since four months ago, and 108 of Brigham and Women's Hospital's 120 primary care doctors have closed their practices to new patients.

Determined patients, however, are getting in to see some of the city's best doctors through informal channels, from e-mailing doctors personally to asking family members and acquaintances to use their connections.

"There is a huge crisis in primary care right now," said Dr. Sherry Haydock, medical director of Internal Medicine Associates, a primary care practice at Mass. General. "If you have a family member already cared for at the hospital, you have a much higher likelihood that a doctor will take you. But as our [practices] have gotten to 150 percent the size they should be, a lot of us realize we have to say no even to family members."

Many doctors blame a national shortage of primary care doctors for the limited access, but the reasons are more complex and vary among hospitals. Many internists, especially women, are cutting back their hours to spend more time with their families. At the same time, the aging population and the increasing complexity of medicine mean that each patient requires more time and services -- reducing the number of patients some doctors can see.

At Boston teaching hospitals, patient demand appears to be growing dramatically, partly because primary care doctors sit at a crucial intersection -- when patients fall seriously ill, it's the primary care doctor who can get them seen by a top surgeon or specialist. And new programs that rate hospitals and doctors' groups on the quality of care they provide often award the highest marks to these institutions, attracting more potential patients.

But many teaching hospitals have trouble finding physicians to hire -- Mass. General averages fewer than two applicants for every opening, down from eight a decade ago. Or the hospitals do not have space to expand. Community hospitals, health centers, and doctors' practices in the suburbs also report difficulty hiring primary care doctors, but most can accept new patients.

All of this leaves many doctors at teaching hospitals feeling caught in the middle and patients frustrated as they try any avenue to get into practices. About a dozen doctors interviewed by the Globe said that in the past few years, they have been fielding a growing number of requests from current patients, colleagues, neighbors, and friends asking whether they can squeeze in someone they know who needs a doctor. Many get dozens of requests a month. Occasionally, hospital executives also ask doctors to fit in major donors.

Doctors have to make uncomfortable decisions about which new patients to accept and which to turn away. The doctors say they turn down most because the more new patients they take on, the longer their current patients have to wait for appointments -- and the more hours they must work.

One doctor said her personal record was 18 requests in three days. She said she accepts few new patients; the lucky ones get in through special requests from colleagues or are family members of current patients or colleagues who ask her at a time when her schedule feels has relaxed some.

Others said that when a fellow physician asks them to take on someone, they often do a mental calculation of whether they may need a favor from that doctor for one of their own patients down the line, such as asking a cardiologist to see a patient with an irregular heartbeat late on a Friday afternoon. And most doctors said they don't feel they can say no when a top executive asks them to squeeze in a VIP.

"There is no ability to get anyone in except as a favor," said Dr. Robert Hughes, a popular internist at Mass. General whose practice is full.

Last summer, Richard Simon, a 74-year-old retired lawyer, landed a prized spot in Hughes's practice. When Simon's longtime physician, Dr. Gerald Foster, retired earlier this year, the hospital assigned his patients, including Simon and his wife, to a new doctor. Because he has an extensive medical history, including colon cancer and a heart attack, Simon said he "wanted someone who knew their way around the MGH, so if things developed and I needed a specialist, he could say, 'Jack Jones is your guy and I'll give him a call.' I didn't think a new guy could do that."

Simon spoke to his cardiologist. "He said: 'Let me see what I can do. All the primary care doctors I know are full. But maybe Bob Hughes will take you on. I've done a few favors for him, and he's done a few favors for me.' "

Mass. General gets at least 25,000 requests a year for primary care doctors, said Dr. Britain Nicholson, the hospital's chief medical officer. That's about twice the number of openings that occur when patients move away, change insurers, or die, creating about one new-patient slot a week per doctor. But the physician-referral call center is not told of those openings, and they're filled instead through informal channels; patients must get personal approval from the doctor to get into a practice.

Nicholson said doctors are more likely to take patients with complicated diagnoses, because they have more reason to be seen in an academic medical center practice. He said the average doctor who sees patients full time has about 1,600 active patients, but most doctors have a smaller load because they also research and teach or work part time.

Paul Ginsburg, president of the nonprofit Center for Studying Health System Change, a policy and research organization in Washington, D.C, said doctors are rationing their time to see new patients based on people's connections, and that could hurt some groups, such as people who have just moved to the city.

"It's not a good situation," he said. "Inevitably, some people are really going to lose out."

Doctors have been warning of a shortage of primary care physicians since early in the decade, when the number of medical students deciding to practice general internal medicine began to fall. Twenty percent chose general internal medicine last year, down from 55 percent in 1998, according to Dr. Thomas Bodenheimer of the University of California at San Francisco, author of an essay on the trend published recently in the New England Journal of Medicine.

The decline is not surprising, given that primary care doctors work a harried pace with unpredictable hours while earning some of the lowest salaries in medicine. Primary care doctors in the United States earned an average of about $160,000 in 2004, compared with $230,000 for obstetricians/gynecologists and $300,000 for dermatologists, according to the Medical Group Management Association, a consulting company.

The Massachusetts Board of Registration in Medicine, which licenses doctors, said about 8,000 doctors list their main specialty as adult primary care. But the board could not provide exact numbers for past years, making it difficult to determine statewide trends in primary care doctors.

Lists of doctors published by health plans often make the situation look rosier for new patients than it is. The state's major health plans generally say that about 20 percent of the primary care doctors in their networks are closed to new patients, but that their lists usually aren't up-to-date.

Bruce Spitler got a job as a project manager in facilities at Beth Israel Deaconess Medical Center last year and wanted to switch to a doctor closer to work. Several colleagues, including a manager in the department, Dennis Monty, recommended Dr. Richard Parker. So Spitler was thrilled to see that the Harvard Pilgrim Health Care website listed him as open to new patients. But when he called Parker's office, a receptionist said the doctor wasn't accepting new patients . Spitler didn't give up. He wrote Parker an e-mail, saying Monty had recommended him.

Parker accepted him. "I've known Dennis a long time and wanted to help him out," the doctor explained in an interview.

Some doctors say one partial solution to the crunch at teaching hospitals is for patients to rethink their biases that experienced doctors are better . "Are all doctors who have longevity in practice the best doctors?" said Dr. JudyAnn Bigby, an internist at Brigham and Women's and medical director of community health programs. "Maybe not. Doctors right out of residency are eager and enthusiastic, they have new ideas, and use electronic medical records to their advantage."

Meanwhile, doctors said they worry that the situation will worsen when thousands of uninsured Massachusetts residents obtain coverage under the state's new mandatory insurance law in the next year.

Many of those residents live in the city and will be searching for primary care doctors.