A Search for Faster Access

Jennifer R. Smith '96 says a UHS nurse called her after a routine blood test to tell her one of the tests was abnormal.

"I asked her which one was abnormal, but [the nurse] said, "I don't want to get into that right now," Smith says.

Smith went in for a retest on a Thursday: and the nurse told her to call her on Monday: Smith left a message, but the nurse did not return her call. Two days later, Smith called again.

"Over the telephone she told me. It looks like you have a tumor in your pituitary gland, but it's really no big deal," Smith says. "It's hard for someone who has just been told she has a brain tumor to comprehend the words, 'no big deal.' I was very upset with the way the information was presented to me."

To mention Dr. Dana Farnsworth around the University Health Services (UHS) is to invoke the name John Harvard outside University Hall. Both names will be recognized, even by those who never knew them personally.

It was Farnsworth, as UHS director 30 years ago, who built up UHS into a facility that may be the best of its kind in the country. And it is Farnsworth vision that today serves as the governing principle for UHS easy access to health care for all members of the Harvard community.

But while UHS's numerous resources and specialists now attract tens of thousands of student visit a year. Farnsworth's vision of easy access has yet to come to function.

Many students say they often have great difficulty obtaining care. According to a Crimson poll of 317 undergraduates last week, only 46 percent said care is "somewhat easy" or "very easy" to access at UHS.

Doctors and administrators say having a primary care doctor is the best way for a student to access the care UHS provides But the majority of students in the survey 63 percent have not enlisted a UHS primary care physician. There was a five percent margin of error in the poll.

An overwhelming majority of more than 80 students interviewed in the past month expressed strong dissatisfaction not only with the quality of care they receive at UHS, but also with their access to that care.

While UHS doctors and administrators largely discount student complaints about care, they widely agree that the health service needs to improve the availability of that care.

"The problem here is access People are real dissatisfied with access says Dr. Peter J. Zaromskis '66, director of the UHS urgent care clime. "I think that's really an important problem. It's because of the constraint of costs."

Dr. Robert Fasciano, chief of the dental health services, says it is especially hard for students to periodically obtain care when they don't fully understand how UHS works.

"Certainly, everything could use improvement," says Dr. Robert Fasciano, chief of the dental health services "I use the health facilities here, and I know how the system works. It's a lot more difficult for someone who doesn't know the system."

In the fall of 1990, UHS scrapped its first-floor walk-in clinic, which allowed any student who wanted treatment to come in and get it, in favor of a new rapid access system of appointments. The walk-in system had caused patients to wait for hours.

Under the rapid access system, sick students who call in are supposed to receive 15-minute appointments either that day or the next--often with a nurse practitioner. Many doctors have touted this as the answer to UHS access problems, but others say it is not.

"People are real dissatisfied with access, and rapid access appointments are less than entirely satisfactory," Zuromskis says. "But it gives students more leeway to get care quicker."

Chief of Medicine Dr. Charles Weingarten says he generally likes the rapid access system because it increases the likelihood that students will be paired up with their primary care provider. But he also says that large health problems, like a recent flu epidemic, occasionally overwhelm the appointment system.

"We work hard on access, and it's a struggle," says Weingarten. "When you do it on an appointment basis, you have a better chance of meeting with the primary care doctor in the system."

Some students have complained that their doctors are rushed during such visits. Weingarten acknowledges that the 15-minute time period can cause problems, but says he sees no easy way of improving it.

"There are tradeoffs," says Weingarten. "If we schedule 15-minute rapid access appointments, that puts the doctor under pressure."

Students have mixed views on rapid access. But many say the system could be worse, none more so than seniors who can still remember the constant chaos of the old walk-in clinic.

"At least since their improvements three years ago, it's been a much improved service," says Victor W. Hwang '93.

Similar health services at other universities have considered options in addition to rapid access. Officials at Yale say they are considering moving regular clinic hours ahead so a full staff will be able to greet students who come after dinner.

"We're thinking about maybe opening later in the morning and closing later at night," says Stephanie Trahan, manager of member services at Yale. "We test-ran it and the staff was happy with it."

Perhaps one of the largest boons for students has been the Harvard University Group Health Plan (HUGHP), HUGHP subscribers include faculty, staff and their families. This increases the patient population and allows UHS to include specialty services such as gynecology, surgery and orthopedics.

"That way lent a lot of strength to the student health service because it allows you to bring in a lot of special its and services you can't usually get at a university health service," Weingarten says.

But the HUGHP plan may also reduce student access to some of UHS's best physicians. Because students are not alone in the UHS community, many veteran doctors say they spend most of their time with older patients.

"I see fewer and fewer students the longer I'm here," says Dr. Mary Wolfman, a part-time primary care doctor and 19-year veteran of UHS. "It takes two or three months for a student to see me. I've been seeing the same HUGHP people and they stick around, so there's not the openings for the students."

UHS officials say that students who have chosen personal primary care physicians are the most satisfied with access to care. While he would not release specifics, Rosenthal points to an undergraduate poll completed last fall to support that claim.

The Crimson poll showed a some-what similar trend. In the survey, 46 percent of students with primary care doctors rated their care "very good" or "good," compared with 34 percent of those who didn't have personal physicians.

A larger criticism of UHS's primary care system is that it restricts access to specialists. This practice of erecting barriers to care, known as "gatekeeping," is used in many health maintenance organizations.

"The positive spin on gatekeepers is that the physician is watching out for you and directs you to the right person," says Dr. David Brooks, acting chief of surgery. "The pejorative--the one I tend to believe--is that the physician keeps you from the specialists you should see anyway."

Fred S. Soo '96, who had an eye problem, says the gatekeeping process kept him from seeing a specialist for over a month.

"I wanted an appointment with an ophthalmologist, but I still got a [primary care] practitioner," Soo says. "I didn't get anything out of it. He didn't tell me what was going on."

Many UHS specialists say they are flexible, especially in case of emergencies only they can handle. But many of these specialists work for UHS only part-time, and the wait for an appointment with them is usually more than a month.

"I think our wait for routine care runs 2-3 weeks," says Dr. Firmon E. Hardenbergh, chief of ophthalmology. "I'm willing to see patients in the early morning, during lunch, after hours."

The problems of reaching a specialist can be a serious deterrent to students with specific medical problems. Thanh A. Nguyen '94 says that immediately before the start of his first year, he was in a car accident. The accident left him with a neck injury and a lot of pain.

But when he called UHS, he was told he'd have to wait three weeks for an appointment.

"The people were nice and all, but there was just so much bureaucracy," says Nguyen. "So I went to see a doctor on the outside. UHS was basically useless."

Rosenthal and primary care providers, however, see no trouble with gatekeeping Dr. Kenneth Gold says primary care physicians like himself serve an important role as referee between different specialists.

"What most people have is six different doctors and no primary care doctor," says Gold. "The doctors don't know what the others are doing. There's no unified care, and the patient suffers."

Many students, particularly those with primary care physicians, praise UHS doctors. But these same students say the real problem with the health service is negotiating a maze of receptionists and nurses, many of whom are insensitive and at times openly belligerent towards students.

Stories like those of Smith, who had to wait six days to find out--over the phone--that she had a brain tumor, are indicative of the lack of sensitivity that accompany UHS's access problem. UHS officials say they would not discuss specific cases with the Crimson. Some doctors agree that sensitivity at the health service needs improvement.

"We're not always the best set-up for access to students," says Dr. Karen E. Victor '80. "Once you are known to a doctor, everything goes all right. But getting to a doctor is not always so easy."

"I do think the receptionists are in a difficult position because they don't have the options to offer the patients," says Victor. "I think that what some students may be experiencing is that their frustration is shared by the receptionist."

Nurses and receptionists at UHS do not receive sensitivity training, doctors note. Bonita A. McCormack, the director of nursing, suggests that such training is something every nurse picks up in regular training.

"Maybe the expectations do vary," says McCormack. "We look at criticism very carefully to correct and do whatever is necessary. And every critique that reaches us we sit down and analyze."

One sophomore says she was shocked by the insensitivity she found when she went into UHS last fall after feeling tired, sleepy and rundown.

"Instead of listening to what I have to say, the nurse practitioner goes into a fit. She says, 'You Harvard people get on my nerves, and one little thing goes wrong, you think you have a disease."

"I just feel there's a general lack of concern," the sophomore says.

While doctors say access should be improved, they say students are wrong to impugn their motives.

"I think it may just be the nature of people when they're sick or not feeling well that perceptions are skewed," says Dr. Ronald B. Matloff, chief of dermatology. "There's an advocate for these gripes, and I've been called up to the advocate to explain what happened on some occasions."

But some students say the patient advocate, Kathleen Diaz, is not easily accessible herself.

Christopher Garofalo '94 says he spoke with Diaz about the immunization therapy he was receiving. Diaz said she would investigate and get back to him, but she never did. Diaz did not return phone calls asking about the matter.

"Here she is, saying we welcome all criticism and complaints," says Garofalo. "But she wouldn't even call me back."

This lack of responsiveness has led some students to seek care elsewhere.

Michelle C. Sullivan '96 says that when she was given a electrocardiogram for a possible irregular heartbeat, she was promised test results the next day. But UHS never called. After two weeks, she went in and got the results herself, but the experience left a lasting impression.

"My mother lives in Cambridge, and I've already had her seek me out a doctor outside," Sullivan says.

A Harvard police officer, who is sometimes charged with transporting students to UHS, says he himself has had numerous bad experiences at the health services.

"Sometimes students ask me whether they should go to UHS or Mt. Auburn," says the officer. "I say, if it were up to me, I'd avoid UHS."

Dr. Tom Workman, director of the emergency room at the Cambridge City Hospital, says that UHS is limited in the kinds of emergencies it can handle.

"We see people when they're [in] unstable [condition]. We see things UHS can't handle," says Workman. "It probably depends on who's covering the service at UHS."

Doctors say that in making care accessible, they are concerned with maintaining diversity within their staff of care providers. Many women, according to doctors and officials, have expressed a desire to see female doctors. And in interviews, some students say they are not happy with UHS's staff diversity.

"Universally, women are often treated more condescendingly," says a female senior. "You have to expend much more energy than [men] do."

Some female students say the sensitivity of the care giver is just as important as the quality of care they receive.

One senior, who spoke on condition of anonymity, said she had been treated by three different male doctors for a mysterious stomach ailment she caught overseas. One of the doctors, she says, questioned her toughness.

As a result, the senior says she has more faith in Nancy Lehrhaulpt, her nurse practitioner, than in the doctors.

"She's a goddess. Every woman on this campus should be going to her for OB/GYN stuff," says the senior. "It was her sensitivity that made me feel a lot better."

UHS officials say they are doing everything they can to be more responsive to such concerns. In responsive to complaints in UHS's own undergraduate survey from last year, Rosenthal says UHS hired its lone female gynecologist.

And at the Law School, where faculty diversity has been an issue, UHS responded with an affirmative action hiring of a Black psychiatrist.

About one year ago, Mary M. Tinkham, assistant director in the international Office, held a seminar for UHS doctors at which international students talked about problems they'd had with the health service because of cultural misunderstandings.

A lack of diversity of races and ethnicities among the doctors is potentially a problem in a health service caring for a diverse community like Harvard's. While 26 of the 66 UHS doctors are women, seven are minorities, according to the 1993 Affirmative Action report.

"One of the problems is that no one wants to be one of a few," says Victor, a female UHS internist. "The issue is that this may not be the most welcoming atmosphere for a minority internist to join. We want to be as welcoming as possible."

But some suggest that in terms of care and patient satisfaction, some kinds of diversity are more important than others.

"I've heard more patients requesting providers who were women than were minorities," nurse practitioner Donna Campbell says.

In the east wing of the third floor, a group of doctors is hatching a plan that may change the way students access care. The rapid access appointment system, these doctors say, breaks down too much, and is routinely changed as nurses and support staff go along.

Some say they have already informally developed an urgency-based scheme with "medium short" appointments--15-minute visits which are flexible and particularly good for follow-ups.

The future may hold bold, new changes in the future that will affect access: a brand new flexible plan for appointments; more educational programs to link students with primary care physicians; broad changes to the UHS floor plan.

For now, UHS administrators, including Rosenthal, seem content to tinker with a system that everyone knows is broken. Some wonder if this is what Dana Farnsworth had in mind.

"It's frustrating for me," says Rosenthal. "Students can do things. I'm available."

The University Health Services terminated its walk-in clinic in 1990, replacing it with a system of rapid access appointments designed to end patients' hours-long waits. But many students and doctors say that system has failed to curb the problem, leaving many patients disgruntled. They want UHS to embark on...

Have you ever visited University Health Services?  Yes  81%How easy is it to obtain routine medical care at UHS?Very Difficult  4%Somewhat Difficult  22Somewhat Easy  21Very Easy  15Don't Know  2

Dr. Robert Fasciano, chief of the dental health services, says it is especially hard for students to periodically obtain care when they don't fully understand how UHS works.

"Certainly, everything could use improvement," says Dr. Robert Fasciano, chief of the dental health services "I use the health facilities here, and I know how the system works. It's a lot more difficult for someone who doesn't know the system."

In the fall of 1990, UHS scrapped its first-floor walk-in clinic, which allowed any student who wanted treatment to come in and get it, in favor of a new rapid access system of appointments. The walk-in system had caused patients to wait for hours.

Under the rapid access system, sick students who call in are supposed to receive 15-minute appointments either that day or the next--often with a nurse practitioner. Many doctors have touted this as the answer to UHS access problems, but others say it is not.

"People are real dissatisfied with access, and rapid access appointments are less than entirely satisfactory," Zuromskis says. "But it gives students more leeway to get care quicker."

Chief of Medicine Dr. Charles Weingarten says he generally likes the rapid access system because it increases the likelihood that students will be paired up with their primary care provider. But he also says that large health problems, like a recent flu epidemic, occasionally overwhelm the appointment system.

"We work hard on access, and it's a struggle," says Weingarten. "When you do it on an appointment basis, you have a better chance of meeting with the primary care doctor in the system."

Some students have complained that their doctors are rushed during such visits. Weingarten acknowledges that the 15-minute time period can cause problems, but says he sees no easy way of improving it.

"There are tradeoffs," says Weingarten. "If we schedule 15-minute rapid access appointments, that puts the doctor under pressure."

Students have mixed views on rapid access. But many say the system could be worse, none more so than seniors who can still remember the constant chaos of the old walk-in clinic.

"At least since their improvements three years ago, it's been a much improved service," says Victor W. Hwang '93.

Similar health services at other universities have considered options in addition to rapid access. Officials at Yale say they are considering moving regular clinic hours ahead so a full staff will be able to greet students who come after dinner.

"We're thinking about maybe opening later in the morning and closing later at night," says Stephanie Trahan, manager of member services at Yale. "We test-ran it and the staff was happy with it."

Perhaps one of the largest boons for students has been the Harvard University Group Health Plan (HUGHP), HUGHP subscribers include faculty, staff and their families. This increases the patient population and allows UHS to include specialty services such as gynecology, surgery and orthopedics.

"That way lent a lot of strength to the student health service because it allows you to bring in a lot of special its and services you can't usually get at a university health service," Weingarten says.

But the HUGHP plan may also reduce student access to some of UHS's best physicians. Because students are not alone in the UHS community, many veteran doctors say they spend most of their time with older patients.

"I see fewer and fewer students the longer I'm here," says Dr. Mary Wolfman, a part-time primary care doctor and 19-year veteran of UHS. "It takes two or three months for a student to see me. I've been seeing the same HUGHP people and they stick around, so there's not the openings for the students."

UHS officials say that students who have chosen personal primary care physicians are the most satisfied with access to care. While he would not release specifics, Rosenthal points to an undergraduate poll completed last fall to support that claim.

The Crimson poll showed a some-what similar trend. In the survey, 46 percent of students with primary care doctors rated their care "very good" or "good," compared with 34 percent of those who didn't have personal physicians.

A larger criticism of UHS's primary care system is that it restricts access to specialists. This practice of erecting barriers to care, known as "gatekeeping," is used in many health maintenance organizations.

"The positive spin on gatekeepers is that the physician is watching out for you and directs you to the right person," says Dr. David Brooks, acting chief of surgery. "The pejorative--the one I tend to believe--is that the physician keeps you from the specialists you should see anyway."

Fred S. Soo '96, who had an eye problem, says the gatekeeping process kept him from seeing a specialist for over a month.

"I wanted an appointment with an ophthalmologist, but I still got a [primary care] practitioner," Soo says. "I didn't get anything out of it. He didn't tell me what was going on."

Many UHS specialists say they are flexible, especially in case of emergencies only they can handle. But many of these specialists work for UHS only part-time, and the wait for an appointment with them is usually more than a month.

"I think our wait for routine care runs 2-3 weeks," says Dr. Firmon E. Hardenbergh, chief of ophthalmology. "I'm willing to see patients in the early morning, during lunch, after hours."

The problems of reaching a specialist can be a serious deterrent to students with specific medical problems. Thanh A. Nguyen '94 says that immediately before the start of his first year, he was in a car accident. The accident left him with a neck injury and a lot of pain.

But when he called UHS, he was told he'd have to wait three weeks for an appointment.

"The people were nice and all, but there was just so much bureaucracy," says Nguyen. "So I went to see a doctor on the outside. UHS was basically useless."

Rosenthal and primary care providers, however, see no trouble with gatekeeping Dr. Kenneth Gold says primary care physicians like himself serve an important role as referee between different specialists.

"What most people have is six different doctors and no primary care doctor," says Gold. "The doctors don't know what the others are doing. There's no unified care, and the patient suffers."

Many students, particularly those with primary care physicians, praise UHS doctors. But these same students say the real problem with the health service is negotiating a maze of receptionists and nurses, many of whom are insensitive and at times openly belligerent towards students.

Stories like those of Smith, who had to wait six days to find out--over the phone--that she had a brain tumor, are indicative of the lack of sensitivity that accompany UHS's access problem. UHS officials say they would not discuss specific cases with the Crimson. Some doctors agree that sensitivity at the health service needs improvement.

"We're not always the best set-up for access to students," says Dr. Karen E. Victor '80. "Once you are known to a doctor, everything goes all right. But getting to a doctor is not always so easy."

"I do think the receptionists are in a difficult position because they don't have the options to offer the patients," says Victor. "I think that what some students may be experiencing is that their frustration is shared by the receptionist."

Nurses and receptionists at UHS do not receive sensitivity training, doctors note. Bonita A. McCormack, the director of nursing, suggests that such training is something every nurse picks up in regular training.

"Maybe the expectations do vary," says McCormack. "We look at criticism very carefully to correct and do whatever is necessary. And every critique that reaches us we sit down and analyze."

One sophomore says she was shocked by the insensitivity she found when she went into UHS last fall after feeling tired, sleepy and rundown.

"Instead of listening to what I have to say, the nurse practitioner goes into a fit. She says, 'You Harvard people get on my nerves, and one little thing goes wrong, you think you have a disease."

"I just feel there's a general lack of concern," the sophomore says.

While doctors say access should be improved, they say students are wrong to impugn their motives.

"I think it may just be the nature of people when they're sick or not feeling well that perceptions are skewed," says Dr. Ronald B. Matloff, chief of dermatology. "There's an advocate for these gripes, and I've been called up to the advocate to explain what happened on some occasions."

But some students say the patient advocate, Kathleen Diaz, is not easily accessible herself.

Christopher Garofalo '94 says he spoke with Diaz about the immunization therapy he was receiving. Diaz said she would investigate and get back to him, but she never did. Diaz did not return phone calls asking about the matter.

"Here she is, saying we welcome all criticism and complaints," says Garofalo. "But she wouldn't even call me back."

This lack of responsiveness has led some students to seek care elsewhere.

Michelle C. Sullivan '96 says that when she was given a electrocardiogram for a possible irregular heartbeat, she was promised test results the next day. But UHS never called. After two weeks, she went in and got the results herself, but the experience left a lasting impression.

"My mother lives in Cambridge, and I've already had her seek me out a doctor outside," Sullivan says.

A Harvard police officer, who is sometimes charged with transporting students to UHS, says he himself has had numerous bad experiences at the health services.

"Sometimes students ask me whether they should go to UHS or Mt. Auburn," says the officer. "I say, if it were up to me, I'd avoid UHS."

Dr. Tom Workman, director of the emergency room at the Cambridge City Hospital, says that UHS is limited in the kinds of emergencies it can handle.

"We see people when they're [in] unstable [condition]. We see things UHS can't handle," says Workman. "It probably depends on who's covering the service at UHS."

Doctors say that in making care accessible, they are concerned with maintaining diversity within their staff of care providers. Many women, according to doctors and officials, have expressed a desire to see female doctors. And in interviews, some students say they are not happy with UHS's staff diversity.

"Universally, women are often treated more condescendingly," says a female senior. "You have to expend much more energy than [men] do."

Some female students say the sensitivity of the care giver is just as important as the quality of care they receive.

One senior, who spoke on condition of anonymity, said she had been treated by three different male doctors for a mysterious stomach ailment she caught overseas. One of the doctors, she says, questioned her toughness.

As a result, the senior says she has more faith in Nancy Lehrhaulpt, her nurse practitioner, than in the doctors.

"She's a goddess. Every woman on this campus should be going to her for OB/GYN stuff," says the senior. "It was her sensitivity that made me feel a lot better."

UHS officials say they are doing everything they can to be more responsive to such concerns. In responsive to complaints in UHS's own undergraduate survey from last year, Rosenthal says UHS hired its lone female gynecologist.

And at the Law School, where faculty diversity has been an issue, UHS responded with an affirmative action hiring of a Black psychiatrist.

About one year ago, Mary M. Tinkham, assistant director in the international Office, held a seminar for UHS doctors at which international students talked about problems they'd had with the health service because of cultural misunderstandings.

A lack of diversity of races and ethnicities among the doctors is potentially a problem in a health service caring for a diverse community like Harvard's. While 26 of the 66 UHS doctors are women, seven are minorities, according to the 1993 Affirmative Action report.

"One of the problems is that no one wants to be one of a few," says Victor, a female UHS internist. "The issue is that this may not be the most welcoming atmosphere for a minority internist to join. We want to be as welcoming as possible."

But some suggest that in terms of care and patient satisfaction, some kinds of diversity are more important than others.

"I've heard more patients requesting providers who were women than were minorities," nurse practitioner Donna Campbell says.

In the east wing of the third floor, a group of doctors is hatching a plan that may change the way students access care. The rapid access appointment system, these doctors say, breaks down too much, and is routinely changed as nurses and support staff go along.

Some say they have already informally developed an urgency-based scheme with "medium short" appointments--15-minute visits which are flexible and particularly good for follow-ups.

The future may hold bold, new changes in the future that will affect access: a brand new flexible plan for appointments; more educational programs to link students with primary care physicians; broad changes to the UHS floor plan.

For now, UHS administrators, including Rosenthal, seem content to tinker with a system that everyone knows is broken. Some wonder if this is what Dana Farnsworth had in mind.

"It's frustrating for me," says Rosenthal. "Students can do things. I'm available."

The University Health Services terminated its walk-in clinic in 1990, replacing it with a system of rapid access appointments designed to end patients' hours-long waits. But many students and doctors say that system has failed to curb the problem, leaving many patients disgruntled. They want UHS to embark on...

Have you ever visited University Health Services?  Yes  81%How easy is it to obtain routine medical care at UHS?Very Difficult  4%Somewhat Difficult  22Somewhat Easy  21Very Easy  15Don't Know  2