Internist Robert H. Blee closed his eyes, pressed his fingersinto his patient's gut and sensed that the pulse in the main arterydidn't feel quite right.
Probably nothing, the doctor thought. But Blee knew that thepatient, Leon Miskin, had ignored his warnings to stop smoking twoto three packs of cigarettes a day. Besides, his cholesterol countwas high.
Deciding that prudence was worth the price, Blee told hispatient to get an ultrasound test from a radiologist who worksdownstairs in his Chevy Chase medical office building. And when theradiologist found the aneurysm - a dangerous, three-inch sac in theweakened lining of the aorta that probably would have killed himwithin a year - Blee sent his patient to a vascular surgeon whoworks on the 11th floor.
That the aneurysm was discovered was more than good luck. Itwas a measure of the way Blee works. In a practice with fourpartners and a dozen employees, he has time to give plenty ofpreventive care. In a neighborhood saturated with doctors, he canreadily refer patients to specialists nearby.
His patients, most of them professionals who are well educatedabout their health, can be demanding. But they are a rewarding grouptoo. They are fun for Blee to talk with, follow his advice most ofthe time and pay their bills.
'That is one of the reasons I want to stay here,' said Blee,who has worked since 1986 on the 14th floor of the Wisconsin Avenuebuilding, just outside the District. 'At least you get paid for whatI do.'
Chevy Chase is a popular location among Washington areadoctors. Blee's office, a few blocks from the Mazza Gallerieshopping mall, is along a commercial strip with good bus service, aMetro stop and plenty of parking in the Saks Fifth Avenue store lotacross the street. Most of the residents of the surrounding housesand high-rise condominiums are well-off and white.
There are 254 doctors with office practices in theneighborhood, including 43 who are internists like him. The supplyof internists is four times as great there as in the metropolitanarea overall, but it is typical of communities stretching from upperNorthwest Washington to Bethesda.
In many ways, Blee is typical of his colleagues there. He worksin a well-staffed medical group. And after 15 years of practice, heis steeped in what has been the culture of care for thewell-insured. But at 43, he also has a big stake in the rapid healthcare changes being made by insurers and the prospect of federallegislation.
Married and the father of two young children, Blee has builthis practice from scratch. After he finished training at GeorgetownUniversity Medical Center, he juggled part-time jobs for governmentagencies for seven years while he accumulated his own patients. Heshared office space with two sets of doctors before joining hiscurrent partners eight years ago.
All internists, those doctors have settled into the niches thatmedicine has formed. Two specialize in endocrinology and one inhematology. Blee is one of the two generalists.
He works conscientiously. Throughout the day, he returnspatients' telephone calls between appointments. He walks, annoyed,to the receptionist's desk, to find out if anyone knew why his 11a.m. patient was a few minutes late.
One late patient can throw off a whole day. 'It pushes youback, and everybody gets irate, and it is a big mess. ... I've hadpeople stomp out of here after 10 minutes.'
If his patients are exacting in their expectations, they alsoare well informed and often seek his advice early. When PatKassebaum, of Silver Spring, visited Blee to check on her stiffshoulder, she brought a list of medical questions about her upcomingvacation in China.
The amenities of Blee's office extend beyond his care. Onefull-time nurse answers patients' call-in questions. She alsoarranges consultations with specialists, at-home care by visitingnurses, physical therapy sessions and appointments with thedietitian who works in the office on Thursday afternoons.
'If the patients want it, they get it,' said the nurse, AnneLafferty.
The office also contains a well-equipped laboratory where fiveemployees analyze blood and urine samples, take X-rays and screenfor breathing, hearing and vision problems.
For tests that are too complicated, the lab sends specimens toan outside laboratory. The two labs are linked by computer, so theoutside one already has records of the tests that Blee wants - andtests the patient has received in the past - by the time thespecimens arrive.
The two bookkeepers in the office's accounting department alsohave computers. About 30 percent of the patients qualify forMedicare, the federal insurance program for patients 65 and older.Nearly all the rest have private insurance.
The office doesn't accept Medicaid, the government insuranceprogram for the poor. Rarely do patients ask about it.
In this well-ordered environment, Blee worries about the future.He thinks the federal government may intensify the pressures on himfrom insurance companies to see more patients in less time, makingmedicine 'just a grind' and making it less likely that he willnotice possible trouble in his patients' aortas.
But he also knows that by working in the group, he always willhave certain advantages: an office manager to handle the hiring andthe payroll, bookkeepers to handle the bills.
'If I was by myself, I'd end up being the chief cook and bottlewasher,' he said. 'We try to keep it simple: Do the doctoring, andhave people help with the other things.'
