Serving patients, in spite of it all

I never imagined it would be like this.

One week ago, an elderly woman came in to schedule a “new-patient” appointment for her grandchild. Her insurance card had my name on it. I have not accepted new patients, unless they are second-, third- or fourth-generation patrons, for years. The insurance companies stopped assigning patients to me more than a decade ago.  Not having patients assigned randomly was so unusual that a staff member was not sure how to handle the situation.

When she came to ask me about it, I hung my head. I knew that if Medicaid was trying to assign new patients to me, it meant they were desperate. Maybe their only criteria to assign patients was knowing the physician could stand upright and had a heartbeat.  Today, that physician was me. Feeling slightly guilty, I wanted to explain to the woman face-to-face why I could not accept even one more patient in my practice at this time. The normal patient load per primary care doctor is 1,500-2,000. I have nearly twice that number. As I walked to the front office, I passed a wall of charts measuring 10 feet high and 15 feet wide.

The woman had kind eyes behind her thick, wire-rimmed glasses. Her hair was a beautiful white, belying her age, and coiffed neatly. She had dressed in her Sunday best before coming to my office that morning, to meet her grandchild’s new doctor. I wanted to cry. Instead, I apologized and led with the truth. I could not add her grandchild to my practice. I gestured to the wall of charts behind me as evidence to support my statement.

Of course, in the waiting room, there was not a single empty seat. On some mornings, patients either wait outside or in their car before being seen. Everyone was watching to see what I would do, but most already knew what I would say. What I had to say. What I hated to say.

I told her that The Doctors Clinic Women’s and Children’s offices were just up the street at St. Michael Medical Center or Peninsula Community Health Clinic — which assumed the patient load after Kitsap Children’s Clinic closed its doors last August— likely had space for her grandchild. Both clinics could provide the care that was needed. She thanked me, slowly, and headed out the door. But that encounter has stuck with me in a way I cannot forget.

Some recent columns have focused on the difficulty experienced by many in this community with finding a physician. This week I am writing to explain our broken healthcare system from a different perspective: my own.

Related: A national shortage of primary care doctors is felt in Belfair, with latest clinic closure

When I started working at this clinic by my father’s side, I knew what an honor and gift it was to work as a pediatrician, a dream since I had been five years old. Early in my career, doubts crept in that I would not be a good-enough doctor for this community. For instance, it was the first day of school in September 2002 and I had no patients on my schedule. None. Not a single runny nose. Not a single broken bone. My father reassured me that someday, my schedule would be fuller than I ever imagined, although I did not believe him.

Over the last fifteen years, fielding a jam-packed schedule has become the rule, rather than the exception. You might think insurers would be happy that patients want to return to the same doctor and office for two, three, and even four generations.  Instead of a pat on the back, insurers are deeply suspicious. They track everything down to the tiniest detail, including cost per patient visit, “quality” measures that are anything but the provision of quality, and even compile “loyalty numbers.” Due to high loyalty numbers, they called me an “outlier,” one state Medicaid program requested copies of my office policy documents. Medicaid assumed I penalized patients who sought treatment elsewhere as an explanation for repeat business. One executive stated with disbelief that “once they go to your clinic, they never leave,” as if I were more mob-boss than doctor.  In truth, when patients go elsewhere, they end up back in my office because the system is a universally broken one no matter where they go. Due to higher-than-average loyalty, insurers place me on a lower “quality” tier, a fascinating example of a upside down system of financial incentives.

Which brings me back to the grandmother standing in my waiting room.

Every time an insurer drops me farther down the preferred list, I am reminded of the roadblocks physicians face daily to care for patients. Each time, I question whether owning a medical clinic is worth all the late nights, early mornings, and missed opportunities.

But then I remember that, next to raising my own children, it has been the greatest joy of my life to know each child who was carried through my doors as an infant and walked out as a full-fledged adult 18 years later. Turning away the elderly grandmother and her grandchild hurts my heart because it is a stark reminder of one child who I will never have the privilege of knowing. While insurers will ding my record for turning away patients they assign, I refuse to stop serving the people, even if it means working in a system I hate. And that must be enough to keep me going for now.

Dr. Niran Al-Agba is a pediatrician in Silverdale and writes a regular opinion column for the Kitsap Sun. Contact her at niranalagba@gmail.com.

This article originally appeared on Kitsap Sun: Serving patients, in spite of it all