It wasn't a big problem. At least it didn't start out that way. We had good initial rapport and found that we had much in common. I liked his friendly reminders to take care of myself and to remember maintenance items like getting my eyes checked and my teeth cleaned. Our encounters were friendly, even humorous. Even when his nose wrinkled at my mention of a chiropractor, I had a sense that he cared for me and for my family.

The first hint of trouble came during last year's annual physical. It seemed to be a busy day in the practice, and the visit was rushed. I had some concerns and was disconcerted when they were met with a dismissive, even flip attitude. I wrote it off to a busy day and decided to mention it later.

My next visit saw the start of a feud between my doctor and my PPO. The PPO had changed laboratories, and both sides seemed determined to put me in the middle of a contract battle over who would pay for what and how I would be treated. Since I was already paying extra to be in the PPO rather than the HMO my company offered — and doing so specifically so I wouldn't have to change doctors — I really thought they should work it out between themselves. After all, the insurance company was getting extra money from me every month, and my doctor was keeping a patient whom he would have lost — and both were working within a contract they had signed freely. I wrote it off to the normal confusions of working with a complicated plan.

After that visit, I followed up to make sure that the problems had been resolved. The PPO assured me that everything was fine, but the doctor's office didn't think so. During my next visit, I was forced to call the PPO while at the office, having been informed that the doctors in the practice had voted not to go along with the new lab guidelines. Instead, they insisted that patients who were PPO members should drive over to the PPO's lab and pay an extra co-pay rather than risk being out a few dollars themselves. They had plenty to say about the low quality of the services I would receive and about the low standards of the PPO in general. They encouraged me to pressure my company to change plans. I wrote it off to a dislike of managed care, a dislike that I share.

For this year's annual physical, I prepared a list. Last year's symptoms were still bothersome and some new ones had cropped up. I did not feel normal, and I was prepared to be more direct with my doctor than last year. I was dismayed that the doctor seemed annoyed with me when I began running through the list. He asked me several times whether I had mentioned my list to the appointments clerk (I had), and he told me my visit was scheduled for no more than 10 minutes. How he could do an annual physical in 10 minutes, even on a totally healthy patient, is beyond me. Again, he dismissed my concerns. When pressed, he agreed to order one test. I wrote it all off to yet another busy day and a mistake by the appointments clerk.

The doctor instructed me to call for the test results in three days. I was surprised to hear I would have to call. I thought, “Shouldn't they call me the day the tests come in?” In three days, I did call, however. I was told that the results were not in. I called every day for three more days and still did not get the results — or an offer to look out for them for me. My fifth call finally turned up the news that the test results were back and that they were negative. I asked what we would do next, since the symptoms were all still there. The nurse said my doctor was on vacation and would call next week. The doctor never called. That, I could not write off.

I could probably have forgiven any of the problems in isolation. Taken as a whole, though, they were unforgivable. My initial favorable impression has been replaced by the impression that the practice cares most about money, less about patient care and least of all about me. I still don't know if I have a minor or major medical problem. I know that I'm still not feeling right, and I have an appointment with a new doctor. Unfortunately for the new doctor, I'm no longer as forgiving as I used to be, and I'll be quicker to change physicians in the future. I guess that's unfortunate for me, too.

If I thought it would help, or if my ex-doctor cared enough to ask, I'd give him several pieces of advice:

• No matter how busy you are, give every patient your full attention.

• Take even minor concerns seriously, and explain why you feel no action is needed.

• Don't put the patient between you and the insurance company. Once you negotiate a contract, stand by it.

• Don't make the patient call more than once for test results. If the test results are late, promise to call when they arrive, and make sure you do it.

• Follow up with your patients. Even if you feel everything is normal, the patient deserves to know what you intend to do and, if you plan to do nothing, that you care about his or her concerns.