I have a new friend on the island. He’s a healthy middle-aged guy who moved here in the past year. His only health issue is hypertension, and he has been on a blood pressure medicine for 5-6 years; he tells me his blood pressure has been well-controlled since being diagnosed, starting the medicine, and making some lifestyle changes. Saw his former doctor last year before his move, but had not needed to see a doctor on island until recently. He works with his hands and works hard, has a family, and had been too busy to think about it.

Two to three months ago, however, he injured his back at work. Only serious enough to keep him out of work for a week or so, but enough to make him think about going to see a doctor. He called 3 local doctor offices was either told that the doctor isn’t taking new patients, that there isn’t an appointment available, or that the office doesn’t handle Workman’s Comp cases. He went to the ER for treatment, and learned that his new health insurance has a $250 copay for ER visits.

While in the ER, he was told that his blood pressure was high, and that he should “consider” increasing the dose of the blood pressure medicine. He doesn’t get a new prescription for this, however.

His back slowly improves, he returns to work. He began taking two of his blood pressure pills every morning, instead of one, but soon afterwards, he felt noticeably more fatigued throughout the day. It was harder to get through a day’s work. He is smart enough to realize that this could’ve been due to the changed dose of his medication. So, he went back to taking one pill a day. Now, however, only had 2 weeks of medicine left on his current prescription. No more refills.

He called the local doctors once again. Out of the five local primary care doctors, he found only one willing to take him as a new patient, but the first appointment available was not for 4 weeks. Not wanting to spend another $250 in the ER, he began to cut his blood pressure pills in half, in hopes of stretching them out and making them last until the appointment.

When the day came, he took an hour off work for his late morning appointment. After checking in at the front desk, he waited 45 minutes before being taken back to the exam room. As the time passed, he became more and more anxious about work responsibilities and the day’s tasks. When he was first seen by the nurse, she mentioned his blood pressure was high, and left him to think about this for another 10 minutes before the doctor came in. He was now anxious enough to get back to work that, after his 10 minutes of face time with his new doctor (including, he says, about a 10-second listen to his heart with a stethoscope, but no other examination), and it was suggested that he increase the dose of his medicine, from 1 pill a day to 2, he decided not to go in to details about how he felt on the higher dose of the medicine and that he had only been taking a half-dose in the 4 weeks leading up to the appointment. He needed to leave.

I was talking with him last week, about a month after that appointment. He decided on his own to pick up the new prescription he received, now for twice as many pills per month as he had been taking, and take them one a day as he had been doing, and enjoy that the prescription would last twice as long and he would not need to return to see the doctor for a while.

I loaned him a blood pressure cuff and suggested he monitor his blood pressure for a week or so and get back to me.

That week, without the pain he had had in his back when he went to the emergency room, and while taking the medication as it had been originally prescribed, and without the anxiety that comes with sitting in a doctor’s office for an hour to spend 10 minutes with a doctor just to get a refill, his blood pressure readings were all normal. He was fine.

And this is Primary Care on Nantucket. This is why I was all too happy to leave the practice I had had here for 12 years, and to take a break from medicine all together.

As for blame? It doesn’t belong to the physician, or to the Emergency Room. You can only do so much with the time that you have, and under the regulatory constraints placed by health insurance and governmental payers.

Nantucket is drastically underserved by Primary Care Providers. Nationally, we have 100 primary care providers (PCPs) per 100,000 people. Massachusetts has 129 PCPs per 100,000 (and yet, with our precursor to Obamacare already in place, about half of the PCPs in the state are no longer taking new patients). The Cape has 99/100,000. The Vineyard has 113/100,000.

If you count Drs. Butterworth, Koehm, Lepore, Pearl, and Steinmuller, and you assume a year-round population of 10,000 (discounting, even, the population swell in the summer), then Nantucket is covered at a rate of 50 PCPs/100,000 people.

THAT is the problem. The delivery of primary care on the island is the single most important health concern for the island. It is not the age or appearance of the hospital. It is not the availability of specialists like cardiologists or endocrinologists. It is the simple fact of not being able to see a doctor (that knows you) when you need to see a doctor.

(photo from flickr user andres.thor)