Becoming a patient in a primary care physician's practice is now almost impossible for Islanders and visitors, but medical personnel are making an effort to alleviate the situation.

Primary physician practices, in the strictest sense, are closed to new patients, leaving those in search of a doctor in limbo.

Tim Walsh, who became the Martha's Vineyard Hospital's chief executive officer in August, said the lack of primary care physicians is a problem.

But he said the hospital is engaged in putting together a staffing plan to determine exactly what the Island needs and to help the hospital provide enough staff to decrease the demands for private practices.

Mr. Walsh said the hardest problem for a physician interested in setting up an Island practice is getting established here, money being the main factor.

The hospital, said Mr. Walsh, has helped physicians begin on the Vineyard by providing loans or by placing doctors on salary.

The hospital helped Ilene Klein set up a practice in July 2001 and her practice is now established.

Primary care physician Beth MacDonald will soon join Dr. Bill Tsikitas's practice on the Island and she is receiving start-up money, a loan from the hospital.

"Ms. MacDonald's coming here will make a big dent in the demand," said Mr. Walsh. "It will be a big help."

Mr. Walsh said a physician is able to handle up to 2,000 patient visits in a year, which may translate into hundreds of patients who previously have been excluded from private practices.

Ms. Klein, the Island's only female primary care physician, said her practice is closed to new patients, but she maintains a waiting list, capped at 35, for them in the event that any of her old patients leave.

"It is a really complex problem here," said Ms. Klein. "If you look at the winter population - probably with Dr. Tsikitas's new physician - the numbers may end up to be just about right, maybe another doctor after that."

But the challenge comes in the shoulder seasons, she said. There are those who stay through October, November and December and who return to the Island in April, May and June. When those are figured in, she said, then there are not enough doctors.

Though not a majority, she said a reasonable portion of her practice includes patients who live on the Island anywhere from four to six months.

"Some have chosen me for their sole primary care doctor, or because of medical issues need a doctor here, or a small group who want a doctor just in case," she said. "I have a smaller subset for the summer months June through September and some of those have complex medical problems."

Mr. Walsh said the uniqueness of the Island poses challenges in planning for patient demand.

"With the summer months," said Mr. Walsh, "the whole system gets strained."

Mr. Walsh said the hospital's goal is to provide enough primary care physicians to meet the demand, a goal that sounds simple enough.

But Mr. Walsh said, "If we go too fast, we will be stressed financially and mess up the system."

Dr. Klein said the solution to the physician shortage is not simply to load the Island with more doctors. She spoke of achieving a "good balance."

"A great first step is to figure out how to work out the calculus of those overlying months where the numbers swell," said Dr. Klein. "If we have all we need for the summer, then we would be twiddling our thumbs in the winter."

Practices have waiting lists for new patients. In the meantime, many turn to the Martha's Vineyard Hospital's emergency room, putting a strain on those resources.

"Some stuff ends up in the emergency room, which is not the best place for primary care," said Mr. Walsh. "And we do lose business to people traveling off the Island for their care."

Adult patients also have access to care at the Island's only year-round walk-in clinic, Vineyard Medical Services, on State Road in Vineyard Haven, open Monday through Friday from 8:30 a.m. to 1 p.m.

The importance of having a primary care physician is clear.

"For primary care, it is really important to have a continuing ongoing relationship with one particular doctor who gets to know you over time," said Dr. Klein. "Because then you have somebody who really understands what your issues are and you have a point of contact when you have a problem. There is really a lot to be said for having a real solid, trusting relationship for when crises come up and someone really gets sick. It's just good to know that you have somebody who knows you well and can distinguish what you are like when you are healthy and when you are not feeling well."

As a primary care physician, Ms. Klein is able to follow her patients into the Island hospital as well as into Windemere, the Island's nursing home and rehabilitation center.

This type of care, she said, ensures a reliable continuity of caring. Such a longstanding patient-doctor relationship provides a patient with a doctor who knows what a patient's treatment requirements are, what the medical problems are, what medications a patient is on and it ensures that tests are not duplicated and that medications are properly prescribed, she said.

Just the notion of routine checkups is important for a healthy life, she said.

Cynthia Mitchell, chairperson of the Island Health Plan, a group invested in providing health insurance to over 3,000 Islanders without it, said she believes over 3,000 Islanders also are not enrolled in a primary care practice.

Without being a part of a practice, the routine preventive visits are not accomplished. "Keeping people healthy and keeping them from getting sick - a lot of that occurs in a primary care visit," said Ms. Klein.

The breakdown of doctors on the Island is as follows:

Doctors caring for patients from birth to 18 are five, two pediatricians and three family physicians.

Doctors caring for patients 18 and above are 12, the above mentioned three family doctors, six primary care physicians and three at the walk-in clinic.

Ms. Klein advised people in search of a primary care physician to remain persistent, to get on the waiting lists at the medical practices and to ask the respective secretaries such questions as how frequently they should call back to check on the wait status or how often to call to let the practice know they are still interested in becoming a patient.

One success Mr. Walsh saw for the summer months was the addition of a hospitalist on staff, who helped with the in-patients, freeing up the time of the primary care physicians.

It worked so well that the hospitalist will come on board a month earlier next summer.

"That [the hospitalist] is a huge help," said Ms. Klein, "but it still doesn't meet all the needs of people who have medical problems in the summer."

But it is not as if someone with an acute medical problem runs the risk of going untreated.

"I do not think any one of us says no to those with serious medical needs. Everybody will find a doctor who can fit such a person into their schedule," said Dr. Klein.

Yet, if the doctors attempt to stretch their practices, the result will be a decline in the overall quality of care.

"Doctors can't take an unlimited amount of patients," she said. "It would compromise care and the patient-doctor relationship."

Even for patients already a part of the practice, the wait for a routine check-up is sometimes long.

Ms. Klein said there are two waiting lists, for those wishing to become a part of the practice and for those who simply want to make an appointment. To get a routine check-up, the wait is usually three months.

"I am busy nonstop from the minute I hit the office, every day no matter what time of year it is," said Ms. Klein.

Dr. Michael Jacobs, at the walk-in clinic, said his practice is open for new patients. "We do not turn anyone away. We see everyone," he said.

But his practice is not considered a primary care practice in the strictest sense, because no one on the staff can see patients into the hospital. The focus for his practice is preventive primary care and preventive medicine as well as follow-up on medical problems.

However, Dr. Jacobs said he is looking to recruit a full-time physician to take care of the hospitalized patients.

"We are trying to fill the gap and the gap of everyday outpatient problems," said Mr. Jacobs. "And the problems that can prevent hospitalization. We are very focused on that."

The walk-in clinic can handle a larger volume of patients than the other practices because it has a "larger staff and is set up to handle a larger volume of patients. If we are doing a walk-in for transients and others with a variety of problems, a lot of them do not require a major follow up. We are geared toward handling a larger flow of patients each day," he said.

Still, Dr. Jacobs agrees there is a shortage of Island doctors.

"The Island needs more primary care doctors who provide more in-care medicine. I support that," said Mr. Jacobs. "We are looking to recruit someone to do just that, and we are 100 per cent supporting everyone's efforts to recruit more doctors."