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The Doctor Dilemma

New York City has more M.D.'s than anyplace else on the planet. So why is the right one harder to find than a rent-controlled six on Central Park West? It needn't be -- you just have to know WHERE to look.

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When I moved to new york from michigan after college, I was baffled todiscover that finding a job (in three days) and an apartment (in four) was alot easier than finding a doctor, perhaps because there was no medicalequivalent of a real-estate broker to whom I could articulate my most basicneeds: reasonable fees, in the neighborhood, warm, accessible, infallible.For a while, I even kept my suburban-Detroit medical team in place,scheduling visits home to coincide with checkups. As you can imagine, thishealth hajj quickly became impractical. But without a network of friends andcolleagues to steer me to the right lab coat, I was reduced to findingreferrals by eavesdropping on conversations in the women's locker room atthe 92nd Street Y and on buses; the results were discouraging, to say theleast.

After a few years of trial and error, I found my internist through my bestfriend's second husband's first wife. I found my dermatologist through mycollege roommate's brother, my radiologist through my husband's cousin, andmy ob/gyn, a fertility specialist, through a former boss who provided theultimate recommendation: She'd just gotten pregnant. Finally, I'm set. Andyou?

New York is a city of doctors, thousands of doctors -- nearly 60,000 at lastcount, the largest concentration in the country. Paradoxically, it's also acity of people searching for first-rate care that meets all theirneeds -- medical, emotional, geographical and, of course, financial. So what'sthe problem?

First, it sometimes seems easier to live with a nagging stomachache orbackache than to deal with the headache of trying to pick from that big poolof docs -- particularly as medicine becomes increasingly sophisticated andpresents more treatment options. You know you need a urologist. Do you go tothe guy who does minimally invasive laparoscopic surgery or the one with themore conservative technique? If you're facing cancer, how do you hook upwith someone with access to treatment protocols for new chemotherapy? How doyou even find out that such protocols exist?

"It's much more difficult now than it once was," says Mark Reiner, a generalsurgeon. "In the old days, the doctor would say, 'You should see Dr. Smith.He operated on my family members.' Today, people are bombarded with ads andnews reports; they're going on the Internet . . . " (This last a thornyprospect, offering reams of unfiltered information but also hospital andphysicians' Websites that can arm you with plenty of useful information.)Patients whose choices are limited by their insurance plans have a wholeother set of issues. Because of anorexic reimbursements from insurancecompanies and the government, doctors have to see seven or eight or twelvepatients an hour to eke out a reasonable income these days -- which meanshurried, harried care. And just when you've found a physician who's a goodmatch, your employer switches health plans, or your doctor of choice dropsout.

What complicates matters is that the doctor you just have to see is -- as oftenas not -- no longer taking new patients. "I think Manhattan people are obsessedwith the idea of the best and whether a certain practitioner is a chicdoctor," says an internist-cardiologist at New York-Presbyterian. "There's alot of he's the only one syndrome, a desire to know the patient profile ofthe doctor and to know whether there are important people in a givendoctor's practice. And of course, there are some doctors who cultivate thatpatient group."

But if your mother was right when she told you there was more than one Mr.Right (or Ms. Right), there's also more than one Dr. Right. "The questionis, why do you need that one doctor?" asks Zeev Neuwirth, an internist atLenox Hill. "Chances are, in New York City, thank God, there is someone elsewho can do that specialized procedure." And if the doctor you desire isn'tavailable, someone else in his or her practice probably is. "You might bebetter off with that doctor's associate," says Neuwirth, "someone who isn'tas senior or doesn't have the same reputation but is equally competent."Indeed, that junior doctor, intent on building a practice, may also takeyour insurance, while the senior guy only takes cash.

Still insist on seeing the big kahuna who steadfastly insists he's taking nonew patients? "If you have another way in to that doctor aside from bullyingthe receptionist, use it," says Stephen G. Baum, chairman of medicine atBeth Israel. "Have your internist call on your behalf. If you know someonewho's been that doctor's patient, have him intervene for you."

Most of us find our doctors through the recommendations of others, and thatcan be a blessing -- or a curse. One physician's type-A-personality bedsidemanner may be perfectly suited to your hypochondriac best friend's needs butnot to your laissez-faire approach to survival.

Whether you're in an HMO or have the means to go to any doctor you desire,nothing is more important than getting comfortable with your primary-carephysician, typically an internist with a specialty in some field ofparticular relevance to you. If you're not comfortable with the gatekeeper,you won't be comfortable with his or her referrals, which are often soughtduring times of crisis, and you'll end up shortchanging your health in waysyou wouldn't dream of doing to, say, your appearance.

If you're fortunate enough to have a friend who's a doctor, ask forreferrals, for scuttlebutt, and for guidance. But Mack Lipkin, a professorof clinical medicine and director of the primary-care division at NYUMedical Center, who frequently finds himself serving as a medicalclearinghouse, says his recommendations are only as good as the informationprospective patients provide at the outset. To get started, you should:
* Familiarize yourself with your HMO's Website in order to get basicinformation about primary-care physicians who match your requirements oflocation and subspecialty. Also useful: medicalconsumers.org, which offersinformation about the number of times a doctor has performed a particularprocedure; and nydoctorprofile.com, a site run by the state HealthDepartment that has information about whether a physician has ever beendisciplined.
* Consider your comfort level with a doctor of the opposite sex (somethingthat women grow up with but that more men are confronting -- maybe not a badthing, since women tend to spend more time forming "partnerships" withpatients). Similarly, is a doctor's age a factor in your comfort level?
* Take into account your special medical needs and likelihood of needinghospitalization. If you are at high risk for a heart attack or requireongoing treatment, you'll want a doctor who has privileges at the hospitalyou need to be in.

Most crucial to lipkin is the tricky task of matching doctor-patient styles.If, for example, your mode of self-care involves vitamins, acupuncture, andthe Alexander technique, you're unlikely to do well with a doctor who eitherdoesn't know from Alexander or doesn't approve of such things. Some peopleprefer to try to change their unhealthy lifestyles and avoid medications -- andfor them, there's no point in going to a doctor who just prescribesmedication. Other things to consider along these lines:
* Do you prefer a doctor who lays out all the options and asks you to decide?Or one who says, "This is what I think would be best"? Or one who says,"This is what has to be done"?
* Do you want a doctor used to sharing a great deal of information, or onewho is more low-key and reserved? "A stock analyst or lawyer or academicneeds information," says Lipkin. "That's their stock-in-trade. They're notgoing to be happy with a doctor who boils something down to the nub. If theyhave congestive heart failure, they want to know exactly what it is and whatit involves rather than being told the pump isn't working."

Our best advice: shop around. we are willing to interview a battalion ofpediatricians before settling on the one who is right for our kids, yet toooften we don't do the same for ourselves. "It's crazy to enter into along-term relationship," says Lipkin, "where your safety and well-being andlongevity are at stake, and not be in the right relationship."If you feel not understood, not cared about," he continues, "if you feelthat you can't ask for a better explanation of something, that you can'tnegotiate the approach to your care, you're not going to be able to tell thedoctor about difficult things like that you're not taking your medicine orthat you're drinking more than you feel is right. You're going to jeopardizeyourself when it really counts. You're going to wake up one night, feelreally sick, and not call the doctor."

So move on. If you can hire a doctor, you can fire a doctor. Here in NewYork, there are plenty more where that one came from.


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