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Dr. Robert Shmerling, a rheumatologist at Beth Israel Deaconess Medical Center, met with a patient earlier this month. The hospital is striving to shorten the wait for appointments.
Dr. Robert Shmerling, a rheumatologist at Beth Israel Deaconess Medical Center, met with a patient earlier this month. The hospital is striving to shorten the wait for appointments. (Wendy Maeda/ Globe Staff)

Long waits for doctors targeted

Hospitals urge faster response

Alison Tomlin was worried that she had skin cancer when she called her dermatologist the first week of September for an appointment. She'd had melanoma once before and knew she was at increased risk when she noticed an odd-looking mole on her torso.

But the receptionist in the office west of Boston said the doctor couldn't see her until mid-November. Tomlin, 35, was stunned and asked for something, anything, sooner. If she was willing to see a new doctor, the woman said, she could squeeze in Tomlin in five weeks.

''I was anxious the whole time," she said.

Excruciating waits like Tomlin's are all too familiar, and recent surveys of patients and doctors suggest that Massachusetts, and the Boston area in particular, have some of the longer waits in the country to see a doctor. Dr. David Roberts, a pulmonologist at Beth Israel Deaconess Medical Center in Boston, said patients, friends, and relatives ask him ''on a weekly basis for help getting in to see someone."

But increasingly, insurers, groups that measure healthcare quality, and market forces are pressing doctors to tackle this problem, which frustrates patients and may delay important diagnoses. Few hospitals are taking the issue more seriously than Beth Israel Deaconess. In July, the hospital hired a new physician-in-chief, Dr. Mark Zeidel, and he immediately set a new goal: He wants doctors to see patients within 72 hours. That's three days.

Waits at the hospital vary widely now, depending on the specialty and the popularity of the individual doctor. But overall, 56 percent of physicians who work in the department of medicine under Zeidel have waits of at least 30 days.

''The culture in medicine is that scheduling is for the doctor's convenience," Zeidel said, speaking of the profession generally. ''The patient can wait. You have to make it a priority to fix it."

Physicians now are working to meet his goal, hiring extra help and rearranging their schedules. Zeidel also changed how the hospital pays doctors as of Oct. 1, offering bonuses for those who see more patients, so that they do not get backed up on waiting lists.

Zeidel is giving doctors up to two years to reduce waits to 72 hours, and he's confident that he will succeed. Before taking his current job, he was chairman of medicine at the University of Pittsburgh Medical Center, where he helped lead a similar effort. As of October, 32 of the hospital's 39 outpatient clinics were seeing patients within three days, executives there said last week.

At Beth Israel Deaconess, a sophisticated computer system tracks wait times for all doctors. And in August, several nurses began ''mystery shopping surveys." They call doctors' offices posing as patients with specific medical problems and write a summary of how they're treated. In the first survey, the nurses made 54 calls; in 13 of them, they did not get an appointment, mostly because receptionists promised to call back and never did.

In addition, the survey found that some receptionists were rude or unhelpful. One caller who posed as a patient with rising blood pressure and difficulty urinating was put on hold for 30 minutes.

Zeidel shared the results with physicians during a meeting one Monday morning in October. ''It was 'peek and shriek,' " he said.

During a follow-up meeting last month, Dr. Robert Brown, a nephrologist, explained that many doctors haven't viewed waits as a bad thing. ''If you were booked for the entire year, you'd say, 'That's great, I'm popular, everyone wants to see me.' I've reveled in having a three-month waiting list," he said.

One administrator in the rheumatology division, which has some of the longest waits, said patients can sign up on a waiting list for the next cancellation. Zeidel grimaced. ''Well we want to get to the point where there is not a waiting list," he said. ''This isn't like getting into Harvard or Yale."

''It's harder!" Roberts, the pulmonologist, piped up from the other end of the table.

In surveying 1,062 physician offices in 15 major cities last year, consultants Merritt, Hawkins & Associates found that Boston had the longest waits for appointments for checkups and minor injuries and pain, from 24 to 50 days. A group of Massachusetts insurers that surveyed their members last year found that 60 percent of patients got in to see a doctor the same day when they ''needed care right away for an illness, injury, or condition," similar to the national average. But for routine care, 72 percent of patients said they got an appointment within 14 days, compared with 84 percent of patients nationally.

Patients usually can get an appointment right away if they have another doctor call -- and many doctors believe that unless they hear from a colleague, the patient's condition is not urgent enough to see them right away, physicians said.

Doctors said it's unclear why waits are longer in Massachusetts than average, especially given that the state historically has had more doctors per resident than any other state. One possible reason is that many doctors work at teaching hospitals, requiring them to do research and teach in addition to seeing patients.

Waits for appointments have become a bigger headache for hospitals in recent years, as tests and treatments increasingly have been shifted to clinics and doctors' offices, making outpatient care a more significant source of revenues.

Insurers are starting to pay bonuses to doctors whose patients give them high marks on a range of measures including prompt appointments. Blue Cross and Blue Shield of Massachusetts does its own ''secret shopping survey" and is starting to pay incentives to doctors who do well.

Tufts-New England Medical Center also is tackling long waits for nonurgent care, which averaged three months in some specialties last year. ''My boss said, 'People are constantly complaining, saying their phone calls aren't answered and they can't get in,' " Denise Schepici, vice president of clinical services, said.

When she studied doctors' schedules, she saw nearly 30 percent of slots were open because patients had canceled at the last minute or didn't show up. By over-booking and by taking cellphone numbers to remind patients of appointments, she said, the hospital has significantly reduced waits for appointments.

At Beth Israel Deaconess, the division of rheumatology, which sees patients with arthritis, lupus, and other immune-system disorders, illustrates the problem of demand for appointments exceeding supply. Doctors logged nearly 10,700 patient visits in the year ended Sept. 30, up from 7,000 five years ago. Ten doctors work in the division, but they are not spending all of their time treating patients.

One doctor hired primarily to do research sees patients for one four-hour session every other week. Another doctor sees patients eight hours a week, spending the rest of his time supervising residents, doctors in training, and teaching. Several doctors work less than full time so they can spend more time with their families. And all the doctors have other responsibilities that cut into their time to see patients, such as helping care for hospitalized patients and teaching classes at Harvard Medical School.

At their last division meeting, the doctors discussed each seeing patients an additional four hours a month, but have not made a final decision. ''This has been a source of huge concern and anxiety in our group, trying to find ways of seeing more patients," said Dr. Steven Goldring, head of the division.

They have persuaded Zeidel to allow them to hire one and maybe two more rheumatologists, he said. Some divisions will use medical assistants or nurse practitioners to see patients coming in for medication checkups or other routine follow-up, making room for doctors to see more new patients.

Tomlin, who lives in Acton, said she feels a one-week wait would have been reasonable to check her mole, which turned out to be benign. Should she have another suspicious mole, she said, she'll ask the receptionist to have the doctor call her back; that way she can describe her concern directly to the doctor.

''I'm not sure that a delay of five weeks makes a difference in whether someone with skin cancer lives or dies," she said. ''It's more about peace of mind."

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